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Section on PAIN

JANUARY

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SERVING THE MEDICAL PROFESSION OF MINNESOTA,
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

Femoral Shortening for
Equalization of Leg Length

i GEORGE M. HART, M.D.

Minot, North Dakota

EQUALIZATION OF DISCREPANCIES ill leg length
has long been considered an important prob-
lem in orthopedic practice. Compensation for
minor differences can readily be made by simply
applying a lift to the sole and heel of the shoe on
the short side. As the difference in length of the
limbs increases, however, the elevated shoe be-
comes not only more unsightly but more difficult
and unwieldy for the patient. It is natural, there-
fore, that reports of surgical measures to resolve
the problem appear earlv in the literature of
orthopedic surgery.

In general, two methods of approach have
been considered: (1) shortening of the long leg
and ( 2 ) lengthening of the short leg. Shortening
of the long leg may be accomplished bv one of
two methods— arrestment of longitudinal growth
by cancellation of epiphysial growth, as first ad-
vocated bv Phemister1 in 1933, or by actual short-
ening of one of the bones of the extremity by
segmental resection. It is with the latter method
that this article is concerned.

Steindler2 noted that femoral shortening was
first carried out in 1847 by Rizzoli, whose claim
of priority has not, however, found much recog-
nition. His method was osteotomy with overrid-
ing of the bone fragments. Two other authors

george m. hart is consultant in orthopedic surgery
at Veterans Hospital , Minot; on the staffs of Trinity
Ho.spital and the Northwest Clinic, both in Minot;
and surgeon for the Soo Line Railroad.

used similar technics, Mayer in 1850 and Sayre
in 1863. In 1908, Glaessner3 reported 2 cases and
Deutschlander4 described fixing the fragments
with an aluminum plate and screws. Shands5
recorded 3 cases in 1917, using wire sutures for
fixation of the bone ends. Fassett9 in 1918 des-
cribed fixation of the fragments with a Lane
plate in 3 cases. In another case, he used a
tongue and groove osteotomy. Royle,7 in 1923,
described 5 cases, 4 of which were fixed with in-
tramedullary pegs and 1 with a Lane plate.

In 1935, White8 described a method of femoral
shortening which has since been widely accept-
ed. He performed a transverse osteotomy of the
mid-third of the femur. The bone fragments
were allowed to override the correct amount and
were fixed by obliquely placed, removable pins.
A plaster hip spica cast was applied from the
toes to the ribs with the hip slightlv flexed and
abducted. The knee was similarly flexed, and the
pins were incorporated in the cast. Eonr weeks
postoperatively the pins were removed. The
cast was maintained for an additional month
and then removed if x-ray examination revealed
sufficient callus formation.

In 1940, Harmon,9 in discussing the surgical
treatment of unequal leg length, noted that
either the tibia or femur could be shortened as
much as 3 in. He felt that femoral shortening
was usually more applicable. The site elected
for this procedure was at the junction of the
middle and lower thirds of the femur. The author

used a Gigli saw to sever the bone transversely
and then removed the desired excess bone with
a hand saw. The excised bone was split into
several fragments, one of which was constructed
to fit snugly as an intramedullary graft. The re-
maining pieces of bone were placed across the
osteotomy site as onlay grafts. Bronze aluminum
wire was used in a number of cases to prevent
separation of the bone ends. The author con-
cluded that although epiphysial arrest was the
most conservative surgical method of equalizing
leg length, it was limited to the seventh to
twelfth years in girls and the seventh to fifteenth
years in boys. He stated that the most exact
universally applicable method of equalization of
leg length was operative shortening of the sound
extremity.

Howorth,10 in 1942, described his operation for
femoral shortening. An osteotomy was carried
out in the mid-shaft of the femur by making drill
holes to step-cut the bone. Separation was com-
pleted with an osteotome. The required amount
of bone was removed, and a bone plate was
applied to the shaft of the femur securing the
fragments. A double hip spica cast was worn
three months postoperatively, depending on heal-
ing.

Blount,11 in 1943, in discussing the use of his
blade-plate for internal fixation of high femoral
osteotomies, mentioned use of the plate for in-
ternal fixation after femoral shortening. A Blount
plate with a single angle was placed in the neck
of the femur, and a screw was inserted through
the proximal hole of the plate into the sub-
trochanteric region of the bone. Osteotomy was
performed distally to the screw, and the required
length of bone was removed from the femoral
shaft. The bone ends were approximated and
additional screws placed through the plate for
fixation.

In 1947, Moore12 described a method of short-
ening through the supracondylar region of the
femur. He noted that, in published reports, the
usual site of election for this procedure was the
diaphysis. He felt that the maximum correction
advisable was about 3 in. and that shortening
in excess of this amount tended to produce per-
manent quadriceps weakness. Moore used a
lateral approach to the distal end of the femur
and sectioned the bone with a Gigli saw just
above the condyles. The shaft of the femur was
displaced outwardly, and a proximal osteotomy
with a Gigli saw was carried out, removing the
required length of bone. The resected segment
was divided longitudinally into several parts with
a motor saw, and one fragment was used as an
intramedullary graft between the femoral cond-

yles and the shaft. The graft was inserted first
into the proximal shaft of the bone and secured
with a single transfixion screw passing through
both cortices and the graft. The protruding end
of the graft was then introduced into the meta-
physis and likewise secured with a transfixion
screw. The remaining bone segments were used
as onlay grafts across the osteotomy site. Post-
operative immobilization was maintained in a
single hip spica cast. The author noted that the
longest period of postoperative immobilization
required was sixteen and one-half weeks in his
series of 15 cases. The average period of im-
mobilization was ten weeks, and weightbearing
with support was begun in the cast six to eight
weeks after operation. In all of his patients,
quadriceps power returned to normal soon after
removal of the cast, and no permanent quadri-
ceps weakness occurred.

Thornton,13 in 1949, described a method of
subtrochanteric femoral shortening. The upper
third of the shaft of the femur and the trochanter
were exposed by a lateral incision, and a Smith-
Petersen nail was placed in the neck and head of
the bone. Osteotomy was performed in the sub-
trochanteric region. A flange of bone was left
extending down along the medial cortex of the
proximal fragment. The required length of bone
was then removed from the distal fragment, the
fragments of bone were brought into apposition,
and a plate was attached to the Smith-Petersen
nail. This was fastened to the femoral shaft be-
low the osteotomy with screws penetrating both
cortices. No external fixation was used postoper-
atively.

White, in discussing Thornton’s procedure,
made a plea for shortening the middle third of
the femur, noting that in 5 of 6 subtrochanteric
shortenings which he had performed, 2 resulted
in delayed union and 1 in nonunion. When he
performed femoral shortening in the middle third
of the bone, no delayed unions or nonunions oc-
curred. J. Albert Key stated, “I have used the
subtrochanteric method and I do not like it very
well.”

In 1951, Eyre-Brook14 described his operative
technic, which was essentially the same as that
described by White except that transfixion screws
instead of metal pins were placed transversely
through the overriding fragments. He noted that
in one of his patients, the leg was shortened 4
in. and normal quadriceps power maintained.

In 1954. Thompson and associates15 compared
results and complications of femoral shortening
by means of oblique osteotomy with screw fixa-
tion and transverse osteotomy with intramedull-
arv nail fixation. The former consisted of placing

2

THE JOURNAL-LANCET

a long osteotomy obliquely through the mid-third
of the femoral shaft. The line of osteotomy was
marked with numerous drill holes, and the oper-
ation was completed with an osteotome. The
distal and proximal spikes were then overlapped
to produce the desired amount of shortening, and
the protruding ends were removed. A fracture
clamp was used to hold the bone ends in apposi-
tion, while 4 transverse screws were placed in
staggered relationship to each other for fixation.
Postoperatively, a single hip spica cast was ap-
plied or the extremity was suspended in a
Thomas splint.

In shortening the femur by transverse osteo-
tomy, Thompson removed the required segment
of bone by making 2 transverse cuts through the
mid-shaft. A Kuntscher nail was then placed in-
tramedullarly to secure the fragments. A staple
was driven across the osteotomy site in several
cases to prevent distraction of the fragments.
The fragment of bone removed during the osteo-
tomy was cut into longitudinal segments and
placed across the osteotomy site as a bone graft.
Thompson concluded from a study of his 2 series
of cases that secure internal fixation was not
provided by intramedullary Kuntscher nail fix-
ation alone. He suggested the use of staples
across the bone ends to prevent distraction of the
fragments. He felt that transverse osteotomv of
the femur with intramedullary fixation was not
a simple procedure and one often attended by
serious complications. As oblique osteotomy with
screw fixation was uniformly successful in his
hands, he preferred this method.

In 1955, Jones"5 described a method of femoral
shortening by “oblique-step” osteotomv and in-
tramedullary fixation. With this operation, the
author attempted to avoid one of the complica-
tions noted by Thompson— distraction of the frag-
ments after osteotomy and intramedullary nail-
ing. He shaped an oblique-step osteotomv so
that the distal end of the proximal fragment and
the proximal end of the distal fragment were
wider than the radius of the shaft of the femur.
The plane of each step then inclined away from
the midline proximally on the proximal fragment
and distallv on the distal fragment to become
slightly less in width than the radius of the shaft.
The two projecting segments locked with each
other when placed together and were held by an
intramedullary femoral nail. No screws were
used, and distraction was prevented by the inter-
locking of the oblique-step projections.

INDICATIONS FOB FEMORAL SHORTENING

Surgical shortening of an extremity is not con-
sidered unless the discrepancy in length is great-

er than 1 in. By tilting the pelvis, a person of
average stature can compensate for shortening
of /2 or of an inch. Inequalities of 1 or 1)1 in.
can readily be corrected by lifting the heel of
one shoe and dropping the opposite heel. Minor
shoe corrections such as these are not readily
noticeable either to the patient or to others.
When the discrepancy in length approaches 1/2
in., however, the patient frequently prefers sur-
gical shortening to a shoe with a built-up sole
and heel of an inch or more.

There are many causes of unequal leg lengths.
Fractures occasionally heal with overriding of
the fragments, producing shortening, or the epi-
physial line may be involved, creating an arrest
of growth. Bone infections, including pyogenic
osteomyelitis, tuberculosis, variola, or syphilis
may produce either relative lengthening of the
involved bone or shortening of the extremity.
Bone tumors may be responsible for differentials
in extremity growth. Neurofibromatosis is fre-
quently attended by enlargement in breadth and
increase in length of an extremity. Congenital
abnormalities, including arteriovenous aneurysms
and congenital absence or malformations of bone,
contribute to variations in leg length. Residuals
of poliomyelitis frequently produce a differential
in the rate of growth of the lower extremities.
Prolonged cast immobilization in growing child-
ren may contribute to a slowing of the growth
of the immobilized extremity.

An inequality of 2 in. or more prevents the
patient from standing with the legs together un-
less the hip and knee are flexed on the long side
and interferes considerably with normal activi-
ties, such as walking, running, sports, and danc-
ing. Howorth noted that his patients desired leg
shortening because of limp, the necessity of
wearing a raised shoe and the associated asym-
metric and undesirable appearance of the foot
and leg. Pain was an unimportant factor. Par-
tial disability in walking, running, working and
playing was present in most of his patients. He
noted that the long leg was usually completely
sound except for occasional minor involvement
in patients whose opposite leg was short as a
result of poliomyelitis.

OPERATIVE LENGTHENING VERSUS SHORTENING

When studying the problem of equalization of
leg length, the first inclination is to correct the
deformity by lengthening the short extremity.
By doing so, the involved rather than the normal
extremity is operated upon, and the patient re-
tains his height. However, because of numerous
complications following leg lengthening proced-
ures, the trend at present is to approach the

JANUARY 1958

3

problem by the less dramatic but safer procedure
of femoral shortening. As noted by White, in
patients with lower extremities differing enough
in length to necessitate an operative procedure,
the short limb is almost invariably sufficiently
involved with atrophic muscles so that further
stretching by a lengthening procedure would
result in inadequate function. Complications of
lengthening include nonunion, postoperative in-
fection, and traction damage to nerves, vessels,
and museles which frequently residt in postoper-
ative deformities of the extremity.

Abbott and Saunders,17 who worked extensive-
ly with the problem of bone lengthening, wrote
in 1939: “We emphasize that the procedure of
bone lengthening is, and in all probability always
will be, a major operation with the possibility
of serious complications.”

A well-founded criticism of femoral shortening
is the fact that the well leg is jeopardized. Be-
side the aesthetic reaction against reducing
height, the possibility of surgical sepsis exists.
However, if this fear on the part of the surgeon
is great, as pointed out by White, shortening of
the long leg should not be attempted.

COMPLICATIONS

Thompson has discussed in detail the complica-
tions following operative shortening of the femur
with intramedullary nail fixation. In his series of
11 patients, 5 operative complications occurred.
In 3 of the patients, the nail was too tight, while
in 2, it was too loose. Fragmentation of the
osteotomy site occurred in 1 patient. This was
regarded as unfortunate because of the possibil-
ity of shortening the leg more than anticipated.
In 2 patients, difficulty was experienced in plac-
ing the intramedullary nail. In 1 instance, the
nail became wedged in the distal fragment of
the femur leaving an excessively long portion of
nail protruding above the greater trochanter. In
another instance, the nail impacted and broke
above the greater trochanter when continued
attempts were made to drive it against resistance.

In 2 patients, the Kuntscher nail fit too looselv
in the medullary canal. Staples were used to
bridge the osteotomy site in 1 of them, and union
occurred without complication. However, in
the other, distraction of the femur occurred, re-
quiring a secondary stapling operation three
weeks later.

Fourteen postoperative complications occurred
in the 11 femoral shortenings performed by
Thompson. These included painful irritation
produced by the proximal tip of the nail at the
greater trochanter; severe and disabling gluteal
pain with sciatica, which was relieved by removal

of the Kuntscher nail; angular deformity caused
bv bending of the nail one month postoperative-
ly; and fracture of the nail.

Genu recurvatum occurred in 4 of Thompson’s
patients after Kuntscher nail fixation. In 3 of
these patients, the femur had been shortened 5
cm. or more. The genu recurvatum persisted in
3 patients from one to five months and in the
fourth for two years. Thompson noted that this
complication had not occurred in patients in
whom femoral shortening had been carried out
by oblique osteotomy and felt that the deformity
was produced by temporary partial loss of muscle
tone in the thigh.

Thompson also noted that secure healing as
demonstrated by x-ray examination seemed to be
obtained more rapidly in patients treated bv
oblique osteotomy than in those in whom fixation
was accomplished by means of an intramedullarv
nail. Although abundant peripheral callus ap-
peared early in patients treated by transverse
osteotomy and Kuntscher nailing, obliteration of
the osteotomy site did not occur until eight to
ten months postoperatively. In patients in whom
oblique osteotomy was performed, union usually
was complete by the end of the fourth month.

TECHNIC

The desired length of bone to be removed is
determined by clinical measurement of the lower
extremities between the anterior superior iliac
spines and the medial malleoli. The patient is
placed upon the operating table in the supine
position, and the limb is draped to expose the
thigh and the region of the greater trochanter.
Using Henry’s18 technic, an anterolateral incision
is made. The rectus femoris muscle is retracted
medially and the vastus lateralis laterally to ex-
pose the vastus intermedins, which is split longi-
tudinally and reflected subperiosteally from the
femoral shaft. A series of longitudinal drill holes
are made through the mid-shaft of the femur,
passing in an anteroposterior direction through
the anterior and posterior cortices of the bone.
These holes are placed in a Z-shaped configura-
tion to outline a step-cut osteotomv. The longi-
tudinal length of the osteotomv is twice the
length of the desired amount of bone to be re-
moved. The drill holes are then connected bv
means of a sharp osteotome, using care to avoid
splintering or splitting the femoral shaft. The
desired length of bone is then removed from
each of the proximal and distal fragments with
a motor saw.

A Kuntscher cloverleaf nail is used for intra-
medullary fixation of the bone. A guide pin is
first introduced into the medullary canal of the

4

THE JOURNAL-LANCET

j proximal fragment and directed proximad to
emerge above the greater trochanter through the
skin of the buttock. The thigh is adducted and
flexed at the hip during introduction of the guide
pin in order to place the point of emergence on
the buttock as close to the greater trochanter
laterally as possible. The proper length of nail
i is determined preoperatively by clinical measure-
ment of the extremity, and the diameter of the
pin is determined during the operative procedure
by introducing nails of various sizes into the med-
ullary canal of the femur. The nail should fit
snugly within the medullary canal but should not
be so great in diameter that the femoral shaft is
split during its insertion. The proper diameter
can be judged by striking the nail with a mallet
and noting its progress into the bone. A nail of
proper diameter will advance 3 to 4 mm. with
each mallet stroke. After the proper sized nail
has been chosen, it is introduced along the guide
pin into the proximal fragment of the femur so
that it is just visible at the osteotomy site. The
femur fragments are then reduced and held with
a bone clamp while the nail is driven into the
distal fragment. X-rays are made on the operat-
ing table in both the anteroposterior and lateral
planes. Films of sufficient size are used so that
the knee joint is visualized to determine the posi-
tion of the distal end of the intramedullary nail.
Two metal screws are then placed transversely
across the step-cut osteotomy to prevent distrac-
tion of the bone fragments. In preparing the
drill holes for the screws, the intramedullary nail
must be missed with the drill point. Sufficient
cortex is present, however, to provide secure
fixation of the fragments with the screws.

Postoperatively, the patient is kept at bed rest
until quadriceps strength is sufficient for active
straight leg raising. He is then allowed to be-
come ambulatory on crutches and instructed to
walk in normal fashion, placing approximately
the weight of the shortened extremity on the
floor. Two to three months postoperatively, if
x-ray examination reveals sufficient callus for-
mation, the crutch on the operated side is dis-
carded. The intramedullary nail is removed in
one and one-half to two years, when the osteo-
tomy site is shown to be completely crossed by
normal bone trabeculae on x-ray examination.

CASE REPORT

J.L.R., age 6, was examined at a crippled children’s
clinic May 8, 1948, by another orthopedist. Examina-
tion revealed a waddling gait, a bilateral positive Tren-
delenburg test, and limited abduction of both hips. A
roentgenogram of the pelvis disclosed bilateral congenital
dislocation of the hips.

She was admitted to Trinity Hospital June 28, 1948,

where Kirschner wires were placed through the supra-
condylar regions of both femurs, and skeletal traction
was applied until August 10, 1948, when the right hip
was exposed through a Smith-Petersen incision. The
capsule of the joint was found to be markedly thickened
and the neck of the femur shortened and anteverted.
The head of the bone was somewhat flattened and the
acetabulum was shallow and filled with fibrous tissue
which was excised. The ligamentum teres appeared
rudimentary. The head of the femur was reduced into
the acetabulum and a rim of bone turned down with a
curved chisel from the ilium, including the upper aceta-
bular rim. Bone was removed from the wing of the
ilium and placed as a wedge above the shelf. A hip
spica cast was applied postoperatively. Skeletal traction
was continued on the left lower extremity until Septem-
ber 30, 1948, when the left hip was operated upon. The
head of the femur was found to lie above the acetabulum,
which was also filled with fibrous and fatty tissue and
excised. The hip was then easily reduced and was
moderately stable. A shelf was turned down from above
the acetabulum, including the acetabular rim, and bone
was taken from the ilium above to form a wedge above
the shelf. A bilateral subcutaneous adductor tenotomy
was also done. A single hip spica cast was applied post-
operatively. The patient was discharged from the hospit-
al December 21, 1948, on crutches.

On February 25, 1949, she was readmitted to the
hospital for physiotherapy and instruction in gait. She
was able to walk fairly well when discharged April 18,
1949. She had a negative Trendelenburg test bilaterally,
but some internal rotation of both lower extremities
and adduction of the right thigh were present. She re-
turned to the hospital July 15, 1949, for a supracondylar
rotation osteotomy of the left femur.

Examination November 1, 1949, demonstrated that
she walked with both feet pointing forward, had negative
Trendelenburg tests bilaterally, and the hips felt stable.

The patient was seen about once yearly bv various

Fig. 1. Roentgenogram of pelvis June 19, 1956, eight
years after bilateral open reduction and shelf operations
for congenital dislocated hips. Shelf on the left has ab-
sorbed, but both hips remain in acetabula and range of
motion is excellent.

JANUARY 1958

5

Fig. 2. Roentgeno-
gram of left femur
August 5 , 1957,
seven weeks after
shortening and fix-
ation with intra-
medullary nail.
Transverse screws
prevent distraction.

orthopedists at crippled children’s clinics from 1949 to
1957. During this time, a gradual relative discrepancy
between the length of the lower extremities was noted.
WHen examined June 19, 1956, leg length was found
to be 3154 in. on the right and 3354 in. on the left. It was
further noted that she walked with a slight right hip
limp and that the Trendelenburg test was negative on
the left but slightly positive on the right. Motion in
both hips was excellent. An x-ray of the pelvis ( figure
1 ) revealed that the hips were seated within the aeeta-
bula. A good shelf was present on the right. The head
of the right femur was somewhat flattened, and the neck
was somewhat shortened. The shelf on the left had
absorbed. She was advised to wear a 1-in. lift on her
right sole and heel, and the possibility of shortening the
left femur was discussed.

She was next seen May 1, 1957, at a crippled chil-
dren’s clinic by another orthopedist. He noted that the
right lower extremity remained 2 in. short and discussed
femoral shortening with the family as the patient was not
wearing a shoe lift for “social reasons.”

The girl returned to the Northwest Clinic, June 17.
1957, at the age of 15 years. Leg length now was 3154

in. on the right and 3354 in. on the. left. On June 18,
1957, she was admitted to the hospital for shortening o.
the left femur. A step-cut osteotomy was made in the
mid-shaft of the femur using a motor drill and an osteo-
tome. The length of the longitudinal limb of the osteo-
tomy was 3 in. to produce 1 54 in. of shortening. One and
one-half inches were removed from both the proximal and
distal fragments of the femur, and the bone fragments
were reduced and held with a bone clamp while a Kunt-
scher cloverleaf intramedullary nail was inserted. Two
metal screws were placed transversely across the tongues
of the osteotomy. Postoperative reeoverv was unevent-
ful. Physiotherapy was started postoperatively and by
July 10 she was able to actively lift her left leg when
lying in the supine position, and ambulation on crutches
was begun. She was discharged from the hospital
July 14.

She was last seen in the office August 5, 1957, walking
well with two crutches. Leg length measured from the
anteriorsuperior spine to the medial malleolus was 31 in.
on the right and 3154 in. on the left. Measurements from
the anterior spine to the upper pole of the patella were
15 in. on the right and 1554 in. on the left. A roentgeno-
gram of the left femur (figure 2) revealed that the frac-
ture fragments and the metal fixation had remained in
satisfactory position and alignment with good callus
formation. She was advised to place about 25 per cent
of her weight on her left leg and to discontinue the left
crutch in about six weeks.

SUMMARY

Femoral shortening is an accepted method of
equalization of leg length after the individual is
past the age when epiphysial arrest is effective.
The advantages of intramedullary fixation can
be utilized if proper selection of nail size is made
and distraction is prevented by internal fixation.

A case report is presented in which step-cut
osteotomy and intramedullary nailing are com-
bined with simple screw transfixion for fixation
and prevention of distraction. The literature of
femoral shortening is reviewed.

REFERENCES

1. Phemistfr, D. B.: Operative arrestment of longitudinal

growth of hones in treatment of deformities. T- Bone & Joint
Surg. 15:1, 1933.

2. Steindler, A.: A Textbook of Operative Orthopedics. New
York: D. Appleton & Co., 1925, p. 174.

3. Glaessner, P.: Die Kontinnitatsresektion der langen Rohren-
knochen zur Ausgleichung von Verkurzungen. Ztschr. Orthop.
30:39, 1908.

4. Deutschlander, K.: Die funktionelle Bedeutung des Langeu-
ausgleiches nach Heine. Ztschr. Orthop. 51:64, 1929.

5. Shands, A. R.: Shortening the long leg. Internat. 1. Surg.
30:273, 1917.

6. Fassett, F. L.: Inquiry into the practicability of equalizing

unequal legs by operation. Am. J. Orthop. Surg. 16:277, 1918.

7. Royle, N. D.: Treatment of inequality of length in lower

limbs. M. J. Australia 1:716, 1923.

8. White, J. W.: Femoral shortening for equalization of leg
length. J. Bone & Joint Surg. 17:597, 1935.

9. Harmon, P. H., and Krigsten, W. M.: Surgical treatment

of unequal leg length. Surg., Gynec. & Obst. 71:482, 1940.

10. Howorth, M. B.: Leg shortening operation for equalizing

leg length. Arch. Surg. 44:543-555, March, 1942.

11. Blount, W. P.: Blade-plate internal fixation for high femoral
osteotomies. J. Bone & Joint Surg. 25:319, 1943.

12. Moore, R. D.: Supracondylar shortening of femur for leg
length inequality. Surg., Gynec. & Obst. 84:1087, 1947.

13. Thornton, L.: Method of subtrochanteric limb shortening. J.
Bone & Joint Surg. 31A:81, 1949.

14. Eyre-Brook, A. L.: Bone-shortening for inequality of leg
lengths. Brit. M. J. 1:222, 1951.

15. Thompson, T. C., Straub, L. R.. and Campbell. R. D.:
Evaluation of femoral shortening with intramedullary nailing.
J. Bone & Joint Surg. 36A:43, 1954.

16. Jones, K. G.: Femoral shortening by “oblique-step” osteotomy
and intramedullary fixation. J. Bone & Joint Surg. 37 A: 575,
1955.

17. Abbott, L. C., and Saunders, J. B. deC. M.: Operative
lengthening of tibia and fibula; preliminary report on further
development of principle and technic. Ann. Surg. 110:961,
1939.

18. Henry, A. K.: Extensile Exposure Applied to Limb Surgery.
Baltimore: Williams & Wilkens Co., 1954.

6

THE JOURNAL-LANCET

Angina Pectoris Treated by Relaxation and
Automatic Attentive Respiration

AARON FRIEDELL, M.D.

Minneapolis, Minnesota

Twenty-one patients in whom angina pec-
toris developed after severe coronary dis-
ease and/or eoronarv thrombosis were followed
carefully between the years 1925 and 1955. Sat-
isfactory results were obtained by teaching them
simple methods of relaxation, mild light physical
exercises, and, most important, automatic at-
tentive diaphragmatic breathing at stated rest
periods three to four times daily with a natural
pause between the respiratory functions.

Of these 21 patients, 12 are living and are
comfortably well. Two died from coronary
thrombosis, and 7 died from other than cardiac
causes. But, all of them were free from pain at
least for more than two years after they learned
the technic of automatic relaxed diaphragmatic
breathing. One was under care for over thirtv
years, and he was presented before several medi-
cal groups to demonstrate the method and ration-
ale of breathing. His death was caused by an
accident after the Christmas holidays in 1955.

This case of H. R. was reported before in
1948. 1 To briefly summarize it, this patient had
an acute myocardial infarction in 1924. He came
under medical care one year later in September
of 1925 with symptoms of angina pectoris, from
which he had obtained relief bv taking nitro-
glvcerin sublingually.

He was taught the method of relaxation and
automatic attentive breathing. He gradually
showed improvement and was symptom-free and
normally active until the day of his sudden death.
He had not needed nitroglycerin nor had he been
confined with any major ailment for twentv-eight
years. His electrocardiograms were always ab-
normal ( figure 1 ) .

The pathologist. Dr. S. T. Nerenberg, stated
in H.R.’s autopsy report: “The main left coronary
artery and descending branch show severe in-
timal arteriosclerosis. The circumflex branch and
right coronary vessels show only mild to moder-
ate intimal arteriosclerosis. On opening into the
cardiac chambers, the left side of the heart is

aaron friedell is on the staffs of Mount Sinai and
Asbunj Methodist hospitals, Minneapolis.

seen to be moderately dilated. The left ventri-
cular wall is hypertrophied. The heart weighs
500 gm. The valves are all grossly normal in
appearance. The right side is not remarkable.”

During the last thirty years of his life, this
patient had spent ten minutes or more two to
three times a day performing this relaxation and
breathing exercise, apparently with good results.

This presentation will not analyze the age and
sex of the 21 patients nor will etiology be dis-
cussed. Two subjects will be presented: (1) the
technic that was used and ( 2 ) the rationale most
likely to produce satisfactory results.

TECHNIC

If an angina pectoris patient was on any medica-
tion when we started our training, he was ad-
vised to continue temporarily. However, the
chief aim has been to reduce the physical and
mental tension and effort. The patient was told
to: “Put yourself at ease at the first appearance
of pain. Bring to mind some pleasant thought
and then relax your entire body. Keep the lips
closed but teeth slightly apart, and, if necessary,
put the tongue somewhat between the teeth so
as to keep them apart, which helps to keep the
jaw and facial muscles relaxed. Then, with the
rest of the body in a state of relaxation, turn the
attention to slow diaphragmatic breathing. Slow
down the breathing without effort, make breath-
ing effortless. Bring the breathing rate down to
6 per minute or less and at ease.”

Some of these patients could breathe at a rate
of only 2 per minute ( figure 2 ) for ten to fifteen
minutes or longer and then feel completely re-
laxed.

Patients were instructed to cultivate effortless
breathing with a pause after inhalation and after
exhalation. The pauses between respirations were
extremely important to our observations, and
that phase will be discussed later.

RATIONALE FOR TREATMENT

1. When the body musculature is at ease, the
oxygen demand is greatly reduced.

Krogh2 called attention in his book, Anatomy

JANUARY 1958

7

Fig. 1. Abnormal electrocardiogram and yet patient folly active and comfortable.

and Physiology of Capillaries, that at rest the
body musculature needs only 1/15, and could
be as low as 1/30, of the oxygen that is required
during marked activity.

Best and Taylor5 showed that slow deep
breathing affords a better oxygen supply than
fast shallow breathing. Thus relaxation and auto-
matic attentive breathing afford a reduced de-
mand and increased supply of oxygen.

2. Slow diaphragmatic breathing reduces card-
iac effort. During inhalation, the lungs widen
and lengthen. According to Macklin,4 the pul-
monary vasculature both lengthens and widens.
So, while blood accumulates in the pulmonary
vessels during inhalation, less blood is returned
to the left side of the heart. Then, too, during
a deep inhalation as the lungs are distended, the
superior vena cava and the subclavian veins are
compressed between the distended upper lobes
of the lungs and the first ribs.5 These vessels are

compressed, and blood is not returned to the
right heart during the latter half of a deep in-
halation. Similarly, the inferior vena cava is verv
easilv compressed between the diaphragm and
the posterior edge of the liver.6 After all, the
pressure in the veins, both superior and inferior
vena cava, is very low— only about 8 to 15 mm. of
Hg. The veins are soft as compared to the arter-
ies, and not much pressure is required to shut
off the return of blood to the right heart. Thus,
during deep inhalation, less blood is returned
both to the left heart and to the right heart. And.
the heart gets a reduced work load after about
the third pulse beat.6

Bearing in mind that the pulsations during the
time of deep inspiration mean less work for the
left heart, we can simplify the explanation for the
benefits derived by taking for an example person
A with a pulse rate of 80 per minute and a res-
pirators' rate of 20 and compare him with person

8

THE JOURNAL-LANCET

Fig. 2. Respiration chart il-
lustrating an automatic res-
piratory rate of less than 3
per minute.

B, whose pulse rate is 80 but whose respiratory
rate is only 4. Then, of course, person A would
have 20 inspirations and 20 expirations which
means 40 actions during that minute of 80 pulse
beats. Dividing 80 by 40 gives us 2 pulse beats
during an inspiration. However, if person B
breathes only 4 times per minute, that means he
has 8 actions— 4 inspirations and 4 expirations—
and dividing 80 bv 8 gives us 10 pulse beats per
minute or 7 pulsations for reduced left heart
effort. That could mean a reduced oxygen de-
mand for the cardiac musculature.

a 80 0 „ 80 1A

A- 40 8 ~ 1

3. Breathing affects the acid-alkaline relation-
ship in the blood and in the other body fluids
and tissues as well.7 Normally, the pH of the
blood is about 7.4 but it shifts with respiration,
7.35 on inhalation and 7.45 on exhalation. That
shift takes place at the usual respiratory rate of
16 to 20 per minute. However, if the respiratoiy
rate is markedly slowed up, the pH shift will be
greater, since, during inspiration, C02 is retained
and increases the hvdrogen ion concentration in
the blood.7 And, since the hydrogen ion has a
very rapid diffusion rate, it affects all other tis-
sues as well.3 So, a definitelv slowed-up respira-
tory rate may well affect the body, possibly
through the Krebs cycle,8 wherever it functions
in the body tissues.

4. I woidd also like to call attention to the
action of the hemoglobin-oxygen pump.9 For, as
the blood flows through the capillaries in the
alveoli of the lungs, the carbon dioxide is de-
livered and flows into the alveolus. On the other
hand, the oxvgen that is present in the alveolus is

absorbed by the hemoglobin and is carried into
the circulations. The carbon dioxide comes into
the alveolus where, if the alveolus is contracting
and ventilating, it is only pushed upward. Other-
wise, since the COL. molecule is heavier than the
02 molecule, it remains and is accumulated in
the alveolus and also in the terminal bronchus,10
and its concentration increases with the increas-
ing pause following an inhalation and exhalation.
While the carbon dioxide content in the air is
only .04 per cent, in the alveoli, it is a little better
than 4 per cent, depending upon the rate of res-
piration. If respiration is slow with a lengthened
pause, then the concentration of 0O2 in the al-
veoli and terminal bronchi is much greater. If
respiration is very slow, the concentration of
C02 may be better than 8 per cent.10 A concen-
tration of COL. of 8 per cent or more has anesthe-
tic qualities and contributes valuably to the
acetvlcholine cycle.11

Gesell and associates11 have shown that the
acetylcholine production in the lungs can be in-
creased fivefold or more with an increase of C02,
since C02 checks the action of cholinesterase
which destroys acetylcholine. So, if respiration
is slowed up to 6 per minute or less, the amount
of C02 in the alveoli and terminal bronchi is
increased and the acetylcholine function is im-
proved. Acetylcholine also has a very marked
permeability rate and even though it is short
lived due to the ubiquitous cholinesterase of the
tissue, in the presence of an increased CO_> con-
centration, its life cycle is longer.1 That, too,
very likely improves the function of the coronary
blood flow by its vasodilator action. Therefore,
slow, automatic, deep diaphragmatic breathing

JANUARY 1958

9

at a rate of 6 per minute or less with a pause be-
tween both inhalation and exhalation can be a
valuable adjunct in the treatment of angina pec-
toris.

5. One may speculate also that with a breath-
ing rate reduced to 6 or less per minute and with
a lengthened and more effective inhalation per-
iod, the diastoles, which take place during such
inhalations, afford a greater gradient of systemic
pressure12-15 in the right auricle than in the left

REFERENCES

1. Friedell, A.: Automatic attentive breathing in angina pec-

toris. Minnesota Med. 31:875, 1948.

2. Krogh, A.: The Anatomy and Physiology of Capillaries. New
Haven: Yale University Press, 1930, p. 57 and 158-159.

3. Best, C. H., and Taylor, N. B.: Physiological Basis of Med-
ical Practice, ed. 3. Baltimore: Williams and Wilkins Co.,
1945, p. 527.

4. Macklin, C. C.: Evidences of increase in capacity of pul-

monary arteries and veins of cats, dogs, and rabbits during
inflation of freshly excised lungs. Rev. Canad. de biol.
5:199, 1946.

5. Candel, S., and Ehrlich, D. E.: Venous blood flow during
valsalva experiment including some clinical applications. Am.
J. Med. 15:307, 1953.

6. Edholm, O. G.: Peripheral circulation. Ann. Rev. Physiol.

12:311, 1950.

7. VanSlyke, D. D.: Acidosis and alkalosis. Bull. New York

Acad. Med. 10:103-137, 1934.

8. Soskin, S., and Rachmiel, L.: Carbohydrate Metabolism,

revised edition. Chicago: University of Chicago Press, 1952,
P. 57.

ventricle. Since during diastole, the pressure in
the left ventricle is supposed to be zero, diastole
at a very slow breathing rate may well provide
an opportunity to call the thebesian and luminal
vasculature into play and, perhaps, improve the
collateral coronary circulation.13,16

In summary, an additional report is made on
automatic attentive breathing and relaxation as
a valuable adjunct in the treatment of angina
pectoris.

9. Draper, W. B., and Whitehead, R. W.: Phenomenon of

diffusion respiration. 28:307, 1949.

10. DuBois, A. B., Fenn, W. O., Fowler, R. C., and Soffer,

A.: Alveolar COo measured by expiration into the rapid in-

frared gas analyzer. J. Appl. Physiol. 4:526, 1952.

11. Gesell, R., Mason, A., and Brassfield, C. R.: Acid hu-

moral control of heart beat. Am. J. Physiol. 141:312, 1944.

12. Gregg, D. E.: Coronary circulation. Physiol. Rev. 26:28,

1946.

13. Lauson, H. D., Bloomfield, R. A., and Cournand, A.:
Influence of respiration on circulation in man. Am. J. Med.
1:315, 1946.

14. MacCanon, D. M., and Horvath, S. M.: Influence of res-

piration on arterial, and right and left ventricular pressures.
Am. J. Physiol. 168:612, 1952.

15. Seely, R. D.: Dynamic effect of inspiration on simultaneous

stroke volumes of right and left ventricles. Am. J. Physiol.
154:273, 1948.

16. Mautz, F. R., and Gregg, D. E.: Dynamics of collateral

circulation following chronic occlusion of coronary arteries.
Proc. Soc. Exper. Biol. & Med. 36:797, 1937.

Hematemesis, melena, or shock is often the first manifestation of acute ulcer-
ation of the gastrointestinal tract which may occur as a result of stress after
cardiac surgerv. These lesions often arise without previous ulceration and
without premonitory symptoms; hemorrhage, perforation, and death mav ensue.
Patients who have responded abnormally to stress in the past appear prone to
stress ulcers. However, this complication cannot be predicted with accuracy.

The abdomen, as well as the heart and lungs, should be examined frequently
after cardiac operations. Sometimes, rectal examination may be advisable to
detect melena. The physician should be alert to the possibility of acute ulcer-
ation in any patient whose progress is not normal after an operation on the
heart.

Immediate transfusion and earlv surgery may he lifesaving. Abdominal ex-
ploration should not he deferred simply because the patient has recently had
a cardiac operation.

Of 7 patients with acute peptic ulceration after cardiac surgery, 4 died and
1 had emergency gastric resection.

Donald Berkowitz, M. D., Bernard M. Wagner, M.D., and Joseph F. Uricchio, M.D.,
Hahnemann Medical College and Bailey Thoracic Clinic, Philadelphia. Ann. Int. Med. 46:1015-
1023, 1957.

10

THE JOURNAL-LANCET

The Diagnostic Value of
Various Ocular Symptoms

ROBERT W. HOLLENHORST, M.D.
Rochester, Minnesota

Many ocular symptoms are so characteristic
that diagnosis may be made solely from the
history. Others are sufficiently suggestive to per-
mit a minimum of delay in proving the diagnosis.
Still other symptoms of organic ocular disease
enable the alert physician to make the correct
diagnosis even though the eyes may be normal
at the time of examination. The discussion that
follows concerns, for the most part, such char-
acteristic complaints and omits those of lesser
diagnostic value.

As the eye is primarily an organ of sight, it is
plain that the major, most frequent, and most
varied complaints are those pertaining to distur-
bances of vision which may occur in one or both
eyes. This paper will center chiefly around var-
ious disturbances of sight and pain, as nearly all
other ocular symptoms are accompanied by rath-
er obvious signs.

DISTURBANCES OF VISION

Complaints due to errors of refraction include
the following.

1. Blurring of distant vision only is usually
due to myopia. It is common among children,
although they are almost never aware of this
visual defect unless the school nurse or teacher
discovers it. Such children often unconsciouslv
but efficaciously better their vision by narrowing
the palpebral fissures. In so doing, they wrinkle
up their noses and their eyelids, a characteristic
gesture. Early nuclear cataracts and uncontroll-
ed diabetes often cause progressive myopia, and,
thus, they produce blurred distant vision without
notable decrease of near vision.

2. Blurring of near vision only is due to just
one thing — inadequate accommodation. It is
found: (a) among hyperopes whose far-sighted-
ness is either undercorrected or inadequately
corrected; (b) among patients of the third and

robert w. hollenhorst is with the Section of
Ophthalmology at the Mayo Clinic and assistant
professor of ophthalmology in the Mayo Foundation.

Read at the meeting of the North Dakota State
Medical Association. Fargo, North Dakota, May 27
and 28, 1957.

fourth decades of life who have subnormal ac-
commodative power or premature presbyopia;
(c) among patients in the fifth or older decades
whose presbyopia has become manifest; ( d )
among patients who have developed a temporary
subnormal accommodation while under treat-
ment for hypertension with the ganglion-block-
ing agents; and (e) among patients who have
had atropine, homatropine, cyclopentolate ( Cy-
clogyl), or other cycloplegics instilled into their
eyes or who may be using systemically excessive
amounts of atropine, belladonna, trihexyphenidyl
( Artane), or other antispasmodic agents. Patients
who have internal ophthalmoplegia as a result of
palsy of the third cranial nerve are usually so
disturbed by the resultant diplopia that they do
not complain of being unable to read with the
affected eye.

3. Blurring of both distant and near vision re-
quires complete ophthalmologic examination, as
it may be due to a variety of causes, such as
uncorrected refractive errors, cataract, glaucoma,
or disease of the cornea, vitreous, retina, optic
nerves, or the higher visual pathways.

Intermittent blurring of vision of both eyes
lasting several hours to a day or more may be
caused by diabetes, for fluctuations in the blood -
sugar level cause changes in the density of the
lens and, therefore, produce variations in the
refractive power of the eyes. Sometimes there
may be a difference of as much as 2 or 3 diopters
on successive days. Intermittent loss of vision of
one or both eyes is a very common symptom of
insufficiency of the basilar or carotid artery and
is usually of four or five minutes’ duration. This
svmptom also accompanies the choked disks of
increased intracranial pressure.

An instantaneous loss of vision in one eye
unaccompanied by pain or other symptoms is
probably due to occlusion of the central artery
of the retina. This is especially true if the patient
awakens in the morning with a sightless eye. If
the individual is more than 60 years old, tempo-
ral arteritis should be considered and ruled out
as soon as possible. Half of such patients go
blind in the remaining eye during the next few

JANUARY 1958

11

hours or days. Patients with temporal arteritis
often complain of transient diplopia or amaurosis
fugax several hours prior to the actual permanent
visual loss. The ophthalmoscope may show a
swollen, hazily seen optic disk and, perhaps,
several cotton wool patches in the retina. The
patient may have had tender scalp arteries, an
influenza-like syndrome, and temporal headaches
for the previous several weeks. He frequently
has an ervthrocvte sedimentation rate of more
than 100 mm. in one hour (Westergren method).
Biopsy of the temporal artery usually corrob-
orates the diagnosis. Very high doses of corti-
sone are a specific treatment for temporal arter-
itis and prevent further loss of vision. There is
no good treatment for occlusion of the central
artery, although oxygen and anticoagulant ther-
apy should he started if the patient is seen dur-
ing the first twelve hours.

A moderateh/ rapid loss of vision in one eye
occurring over a few hours to a day is usually
due to one of the following: (1) occlusion of
the central vein, which causes red vision if the
hemorrhage extends anterior to the retina into
the vitreous; (2) acute glaucoma when the visual
loss is accompanied by seeing rainbows around
lights, severe pain, cloudiness of the cornea,
dilatation of the pupil, and redness and hard-
ness of the eye; (3) acute iritis, with moderate
pain, miosis, cloudiness of the aqueous and red-
ness of the eye; and (4) optic neuritis, which
causes pain on moving the eye, more rapid loss
of vision, diminished pupillary reflex, and papil-
ledema. The same symptoms occur with retrobul-
bar neuritis, but the disk then looks normal at
first.

Loss of vision in both eyes, whether rapid or
slow, is caused by bilateral intraocular disease,
lesions of both optic nerves, a lesion of the optic
chiasm, or a lesion of the higher visual pathways
in the cerebrum. Immediate further ophthalmo-
logic and neurologic investigation is indicated.

In addition to losses of vision, such as those
previously described, a host of interesting entop-
tic visual disturbances may bring the patient to
the physician for examination. The patient's de-
scription of most of these disturbances is sufficient
for making the diagnosis on the basis of the
history alone.

The most common disturbances, of course, are
represented by the so-called floaters, spots, or
muscae volitantes. Almost everyone can see
against the background of blue skies, snow, and
bright ceilings the small cobwebby or stringy
threads which always float away when one tries
to look directly at them. These are small rem-
nants of the fetal vascular system or condensa-

tions ol the vitreous and have no pathologic sig-
nificance. Often, a patient who complains of
these disturbances and comes for advice is in
an anxiety state or has another, more severe
psychiatric problem. Such patients frequently
complain also of other entoptic phenomena. They
may be alarmed by the dancing lights that are
seen when the lids are closed over the eyes. Thev
fearfully observe the after-images that are always
present after gazing at bright objects. They often
have learned to prolong the duration of these
images by blinking their eyes slightly from time
to time. Thus, instead of disappearing in a few
seconds, these after-images may persist five min-
utes and longer. Some patients observe the very
interesting entoptic phenomenon in which if a
bright surface, such as the sky, is observed, they
may see a great number of small dancing spots
like electric sparks which shoot up suddenly
along a curved short path and then disappear
as abruptly as they appeared. These are prob-
ably red blood cells going through tiny capil-
laries in the macular portion of the retina.

Another interesting but pathologic visual phe-
nomenon is called “ Moore’s lightning streaks.”
These are seen more frequently by persons in
their fifties, sixties, and seventies but may appear
at any age. They come as sudden, bright, light-
ning flashes in one eye, almost invariably in the
far temporal field. Turning the eyes rapidly,
shaking the head, or, often, merely walking down
a stairway will produce the phenomenon. The
cause is a degenerative shrinkage of the vitreous
of the eye. In attempting to separate from the
contiguous retina, a strand of vitreous tugs and
pulls on the retina and causes the lightning
streaks. The vitreous continues to shrink and
eventually separates completely from the internal
limiting membrane of the retina. When this oc-
curs, the patient notes the advent of several
large floaters in his field of vision, but the light-
ning streaks will have gone and will not return.
During the period in which the lightning streaks
are seen, there is danger the retina may be pulled
oil, especially if a strand of the vitreous tugs on
a cvstic space in the retina. Therefore, such
patients should have a thorough ophthalmoscopic
examination through a widely dilated pupil, us-
ing 2 per cent solution of homatropine hvdrobro-
mide and 10 per cent solution of phenylephrine
( Neo-Synephrine) hydrochloride, to rule out in-
cipient retinal detachment. Sometimes, a small
hole is found without detachment of the retina.
This is, of course, the ideal time to surgically
close such a hole. After the streaks are gone and
the floaters appear, the danger of retinal detach-
ment is probably over.

12

THE JOURNAL-LANCET

A similar but quite different visual phenomenon
is sometimes described as a “lightning streak.”
This is the peculiar and characteristic scintil-
lating scotoma of migraine which takes many
forms. However, careful questioning ordinarily
leaves no doubt as to the diagnosis. The visual
symptoms appear during the aura, supposedly
during the period of vasoconstriction of the cere-
bral vessels. The patient may suddenly see a
bright spot of light a little to one side of the
axis of his vision. The spot begins to expand and
then he notes a loss of part of the letters of words
he tries to read, or he may see only the right
half or the left half of objects he regards with
either eye or with both eyes. The bright area
begins to expand further, and it pulsates at a
rapid rate (computed to be about 10 beats per
second, comparable to the rate of the alpha
rhythm in the electroencephalogram). It may
expand to fill either the same quadrant in each
eye or a whole homonymous half-field, and it
may be brightlv colored. At its maximum, the
whole phenomenon suddenly disappears in a
maelstrom of light. The episode usually lasts at
least ten minutes and sometimes as long as thirty
minutes. Shortly after the aura is over, the head-
ache develops. It usually affects the side of the
head opposite to the visual aura and, therefore,
corresponds to the part of the brain from which
the aura emanated. Sometimes, the visual phe-
nomena may be so-called “fortifications.” These
are figures which look like the top of an ancient
battlement. Other patients may merely see snow-
flakes or dancing twinkling lights or experience
a sensation as of heat waves. Some patients have
a homonymous hemianopsia without scintillating
lights, which may last ten to thirty minutes.
Those who have this phenomenon must be eval-
uated carefullv to be sure an intracranial lesion
is not overlooked. Intermittent insufficiency of
an internal carotid artery or of the vertebral or
basilar arteries may produce a transient homonv-
mous hemianopsia, but never, or almost never,
such scintillating scotomas. Many patients who
have the tvpical visual aura of migraine are
spared the headaches and suffer only the terrify-
ing visual symptoms.

Patients with tumors of the temporal or occipi-
tal lobe sometimes see images or scenes of vari-
ous types. These are quite different from the phe-
nomena that are described by patients who have
ocular migraine, although these phenomena too
may appear for short periods. They may occur
with increasing frequency several times a week
or even daily, in contrast to migraine equivalents
which usually have occurred for years and, ordi-
narily, only once or twice a month.

Patients who have tumors in the parietal
lobes are sometimes bothered by peculiar visual
disturbances which come periodically. These rare
phenomena consist of a confusion of right and
left and, sometimes, of an inversion of the envi-
ronment. Such patients may note that people
seem to be walking on the walls of the room in
a horizontal position rather than on the Hoor.

Micropsia is the term applied to the visual
phenomenon in which objects appear smaller
than they really are. This is commonly due to
spasm of the accommodation and is observed
among patients whose accommodation is partial-
ly paralyzed as in early presbyopia. Voluntary
convergence and concomitant accommodation
produce micropsia. It is sometimes the present-
ing complaint in psychiatric patients. Patients
who have edema of the macula may have this
symptom, although more often they, have meta-
morphopsia.

Macropsia, in which images seem larger than
normal, occurs when there are scars in the retina
and is rarely observed.

Metamorphopsia, the condition in which the
shape of objects is distorted so that a square
looks asymmetric or a circle looks oval or a
straight line appears bent, usually results from a
disturbance of the macula by edema, hemor-
rhage, choroiditis, detachment of the retina, or
other lesions. A hole in the fovea may cause a
straight line to be seen as a bisected or bent line.
Improperly corrected astigmatism may distort
the entire environment so that objects appear
twisted or closer or farther away than they really
are.

Colored vision, so-called chromatopsia, is al-
ways indicative of some type of pathologic proc-
ess. Rainbows seen around artificial lights are
caused by edema of the cornea, as in acute con-
gestiye glaucoma, and sometimes by nuclear
cataracts. Rainbows caused by cataracts are
constant, while those due to glaucoma appear
with a rise of intraocular pressure and disappear
when the pressure becomes normal. Red vision
occurs among patients who have preretinal
hemorrhages or hemorrhage into the vitreous.
Exposure to snow or bright lights, aphakia, iri-
dectomy, or prolonged dilatation of the pupil
may also lead to red vision. Yellow vision mav
be associated with jaundice, santonin poisoning,
or carbon monoxide poisoning. White or blue
vision may be caused by digitalis intoxication;
sometimes objects may appear to be covered
by snow.

Photophobia is a common complaint. Organic
lesions of the eyes cause severe photophobia.
These lesions are always easilv discovered bv

JANUARY 1958

13

examination and consist of albinism, lesions of
the cornea, and inflammatory involvement of the
internal eye. Most people are more comfortable
in bright light if they wear colored glasses. How-
ever, photophobia is often a symptom of severe
psychoneurosis; such individuals seem to find
security behind dark glasses and wear them even
indoors, a form of purdah.

Oscillopsia is an interesting manifestation of
cerebellar or pontine dysfunction. There may be
no visible disturbance of eye movements, al-
though sometimes there is nystagmus. The
patient complains of inability to recognize people
unless he and the person he is attempting to
recognize are stationary. One woman complain-
ed that whenever she walked into a room, she
could not identify any of her friends sitting or
standing until she herself had come to a stand-
still. This phenomenon is usually due to multiple
sclerosis but sometimes to other lesions of the
pons. It has been observed as a toxic effect of
streptomycin on the vestibular nerves. The symp-
toms result from ataxia of the ocular movements
so that the eyes cannot move smoothly from one
point of fixation to another.

Double vision requires complete ophthalmo-
logic and neurologic examination. It indicates
serious intracranial disease as a rule, since it is
due to paresis of one of the extraocular muscles.

Triple or quadruple vision is caused by abnor-
malities in the cornea, lens, or vitreous of one or
both eyes. Diplopia in one eye may have the
same etiologic basis.

Night blindness, in which the individual has
trouble seeing in dim light, is the result of loss
of function of the rod cells in the retina and is
most frequently due to degeneration of the ret-
ina as in retinitis pigmentosa or, more rarelv, to
deficiency of vitamin A.

PAIN

Pain in and about the eyes may come from a
multitude of causes, some due to ocular disease
and others not in any way related to the eyes.
Pain may be unilateral or bilateral. It may be
aching, boring, sharp and stabbing, scratchy,
burning, or itching in character.

A sharp stabbing pain results from a lesion of
the epithelium of the cornea and is often followed
by a scratchy sensation. It is the characteristic
pain of a foreign body on the cornea or lodged
under the upper lid scratching the cornea. The
scratchy sharp pain is accompanied by profuse
laerimation and severe photophobia.

A patient, usually a young married woman,
frequently complains that she is awakened every
night between 2 and 3 a.m. by a sharp, very

severe knife-like pain in one eye. The pain lasts
ten to fifteen minutes and during this time the
eye also feels scratchy. When the pain is gone,
she falls asleep again and has no trouble the rast
of the night. The next morning when she has the
eye examined, the physician finds nothing to ac-
count for her symptoms and passes the episode
off as of no consequence. Such patients some-
times go from physician to physician until finally
one recognizes this sequence of events as the
characteristic symptomatology of recurrent ero-
sion of the cornea. Usually, some weeks or
months before, the eye may have been scratched
by a baby’s fingernail or other foreign body. The
abrasion probably healed promptly. However,
such abraded areas may remain roughened and
the epithelium may not grow securely to the
basement membrane. Thus, when the lids are
closed in sleep, the epithelium of the lid and
that of the cornea may grow together. A slight
movement of the lid in sleep then rips off the
piece of cornea, thus producing the characteristic
chain of events. Duration of the pain is only
ten to fifteen minutes because the wound heals
rapidly. Simply instilling boric acid eye oint-
ment liberally at bedtime for several consecutive
days heals this lesion. Tetracaine (Pontocaine)
drops instilled during the height of the pain pro-
duce immediate relief. Recurrent corneal blebs
may produce similar symptoms.

The so-called ether burn of the cornea, occur-
ring when a patient wakes up from general
anesthesia with a severely painful, scratchy,
photophobic eye, is not an ether burn at all but
an abrasion of the cornea caused bv brushing
the cornea inadvertently or else by allowing the
lids to remain partially open and thus drying and
macerating the cornea. Use of tetracaine (Pon-
tocaine) and a patch relieves pain until the cor-
nea is healed.

Burning of the eyes, aggravated by tobacco
smoke in the air and sometimes accompanied
bv scratchiness and photophobia, is usuallv due
to dry eyes (keratitis sicca). This condition is
often associated with a dry cottony mouth, sour
stomach, constipation, and, usually, with arthri-
tis. It is caused by a systemic alteration in the
production of glandular fluids on the serous sur-
faces of the body. Tear secretion, as tested by
Schirmer’s method of inserting a strip of filter
paper over the lower punctum, will be absent
or minimal in a five-minute test period. Fluores-
cein will stain innumerable minute areas of
epithelial erosion of the corneas, which are vis-
ible only by biomicroscopic examination. The
medication used is artificial tears, an isotonic
solution of methyl cellulose ( Isopto-Alkaline ) ,

14

THE JOURNAL-LANCET

which is effective in 98 per cent of patients. The
other 2 per cent may be helped by using a prep-
aration of their own blood serum made under
sterile conditions.

Itching of the eyes almost invariably denotes
an allergic condition of the eyelids or conjunc-
tivae. Pollens, cosmetics, house dust, and animal
dandruff are the most common causes. Two
diseases of the eylids cause itching: (1) angular
conjunctivitis and (2) vernal conjunctivitis. The
former, an infection of the lids and conjunc-
tivae caused by a diplobacillus, frequently occurs
in aged people and is manifested by a distressing
itching of the lids accompanied by Assuring at
the outer canthi. It responds well to 1/3 per cent
zinc sulfate drops administered four times daily
for about a month. People with vernal conjunc-
tivitis have a well-known way of rubbing their
itching eyes by grinding the heel of the hand into
the orbit. If the examiner everts the upper lids,
he will see large cauliflower-like vegetations of
venial catarrh. Treatment with hydrocortisone
or prednisone drops is effective.

The severe pain of acute glaucoma has been
mentioned. Chronic simple glaucoma does not
usually cause pain in the eyes. The pain of
iritis is much less severe. A patient who has optic
neuritis or retrobulbar neuritis often complains
of pain when the eyes are moved. Scleritis causes
a severe, deep, orbital pain which is aggravated
by turning the eyes. This disease not infre-
quently accompanies rheumatoid arthritis and
may develop in a very severe form in arthritic
patients who have been treated with steroids
for a long time and who have had the hormone
withdrawn too rapidly. The treatment consists of

either systemic or subconjunctival administration
of steroids.

A patient may periodically experience very
severe pain deep in one orbit, which lasts one to
two hours. These attacks usually occur in the
spring and fall and cause excruciating pain
which is generally at its worst during the night.
Each pain rises rapidly to peak intensity and is
accompanied by redness of the eye, lacrimation,
stuffiness of the corresponding side of the nose,
and, sometimes, by constriction of the homo-
lateral pupil. Such a patient, of course, has his-
taminic cephalgia or so-called cluster headaches.

Other types of pain which may be in the
vicinity of the eyes include the scalp pain of
temporal arteritis, the characteristic burning
pain of herpes zoster, and the electric-shock
pains of trigeminal neuralgia. Patients with an
intracranial aneurysm may have severe pains
above one eye accompanied by Horner’s syn-
drome on the same side.

Finally, there is a little known unilateral
orbital pain some people experience when the
nasal mucosa at the ostia of the nasal sinuses
is congested or when the turbinates lie in con-
tact with congested mucosa. Such pain is often
present on awakening, may be aggravated by
consumption of alcohol the night before, and
can be prevented by lying at night with the
painful side of the head turned up. Nasal decon-
gestants often relieve this headache promptly.

Milder forms of pain are occasionally the re-
sult of uncorrected refractive errors and, some-
times, of uncorrected muscle imbalance of a
mild degree. Large amounts of muscle imbal-
ance do not usually cause ocular pain.

Hypoglycemia, with extensor rigidity of the extremities, coma, and acidosis,
can occur as a result of intoxication with Solox, a paint solvent.

Solox, consists principally of methanol and ethvl alcohol and is often ingested
by chronic alcoholics in the southern states. Many persons drink this fluid re-
peatedly with no ill effects. However, occasional patients are hospitalized be-
cause of coma, blurred vision, cramping abdominal pain, or burning of the eyes.

Physical findings include foul breath and chest rales like those of hydrocar-
bon or aspiration pneumonitis. Mania, convulsions, widely dilated pupils,
generalized flaccidity, decreased gag and cough reflexes, loss of deep tendon
reflexes, or extensor rigidity of hvpoglvcemia may be noted.

The carbon dioxide combining power and blood sugar concentration are
low; blood ketones and lactate are increased.

Treatment includes: (1) correction of acidosis by intravenous administration
of 2 per cent sodium bicarbonate solution; (2) reversal of hypoglycemia by
intravenous infusion of hypertonic dextrose at four- to six-hour intervals for
the first twenty-four hours; and (3) supportive care, including antibiotic ther-
apy if aspiration has occurred. Pressor agents may be needed to combat shock.

William J. Hammack, M.D., Veterans Administration Hospital, Birmingham, Alabama. J.A.M.A.
165:24-27, 1957.

JANUARY 1958

15

Care of the Patient with a Colostomy

WILLIAM C. BERNSTEIN, M.D.

St. Paul, Minnesota

There is much misunderstanding and mis-
information relative to the status of the pa-
tient with a colostomy, and I hesitate to admit
that much of this misinformation originates with
physicians. Far too many doctors feel that a
colostomy is a dreadful contraption that must
not be considered for a patient except as a last
resort. The truth of the matter is that a well-
functioning colostomy is a wonderful device that
makes it possible for people with serious illnesses
and malignant tumors to be restored to health.
These people can live relatively normal lives and
can be economically independent and socially
acceptable. Experience in caring for a large
number of patients for many years has convinced
me that an intelligent and cooperative patient
does not feel that his colostomy is much of a
handicap. However, we cannot expect all pa-
tients to be intelligent and cooperative, but we
should expect every doctor who assumes respons-
ibility for the care of patients who need this type
of surgery to equip himself with the necessary
information on the subject. Unfortunately for
the patients, too few physicians have shown
enough interest in colostomy problems in the
past. A surgeon may perform an excellent bowel
resection and provide the patient with a good
anatomic colostomy, but, if that patient is not
given proper instructions regarding the care and
function of the colostomy, he soon is in trouble.
He becomes miserable until an attempt is made
to help him adjust to his new way of life. By that
time, some patients have become depressed and
quite unable to cope with the problems involved.
A planned method of approach by the physician
before surgery, during the period of hospitaliza-
tion, and during the period of convalescence
usually pays big dividends in helping the patient
adjust to his new situation and to become reha-
bilitated in his family and outside environments.

When a patient learns that he has a veiy ser-
ious illness which often is due to a cancerous
tumor, the blow is hard to take, Add to this
trauma the knowledge that a colostomy must be

WILLIAM C. BERNSTEIN US' clinica 1 USSOCWte pwfeSSOr

of proctology in the Department of S urgert/ at the
University of Minnesota.

performed and that he will have to accept a com-
plete change in his bowel elimination and the
shock is often overpowering. At times, the effect
on the patient is so serious that he may refuse
surgery altogether. In other cases, the patient
may become depressed and feel that his future
will be dark and dismal. It is at this point that
an understanding and well-informed physician
can do a tremendous amount of good. The
choice of words used in describing a colostomy
is very important. A colostomy should never be
referred to as “an opening in the side.” This ex-
pression came into use about 1800 when the first
lumbar colostomy was performed by Callisen1
in Copenhagen. To my knowledge, no one has
performed a “side” colostomy since the 1890’s.
A few minutes devoted to an explanation of
how a colostomy works and how it can be regu-
lated, augmented by a few well-chosen case
histories of persons who are completely rehabili-
tated, does much to restore the patient’s equilib-
rium and implant a feeling of hope and confi-
dence. Merely to tell a patient that the rectum
must be removed and that an artificial opening
will be made on the abdomen is, to my mind,
a cruel approach and must produce frightening
thoughts in patients.

Much has been written in recent years on this
subject. Lay persons as well as physicians have
become aware of the gravity of this problem and
have taken an active part in the educational pro-
gram for physicians and patients. In some cities,
clubs have been formed to help in the rehabili-
tation of colostomy patients. These organizations
have done much to lessen the load of the physi-
cians and to improve the mental attitude of the
patients. They have also made available much
information concerning newer technics and ap-
pliances which may be of use to colostomv
patients.

Each doctor must approach this problem in
his own way. However, since the ultimate goal
is the same in each case, namely, a well-adjusted
and rehabilitated patient, certain basic principles
must be observed. I will attempt to describe
our approach in the handling of these patients,
since we feel that the end results have been uni-
formly good. When we diagnose cancer of the

16

THE JOURNAL-LANCET

rectum or any other disease requiring a perma-
nent colostomy, we explain that the surgery will
entail construction of a new opening, which will
serve very satisfactorily and with little inconven-
ience to the patient. We assume a very optimis-
tic attitude and try never to instill a feeling of
doubt or fear in the patient’s mind. We are quite
positive in our approach and, if the patient mani-
fests some real anxiety, we suggest that we will
he glad to bring in a patient who has a colostomy
and who is happy with it. We try to forewarn
the nurses on the hospital floor where the patient
is to be admitted so that they will assume an op-
timistic attitude toward the patient and his ill-
ness. A thoughtless nurse can destroy all of the
confidence the physician has built up in the
patient. We have had several bitter experiences
resulting from tactless remarks about those “aw-
ful” colostomies. Some nurses offer unsolicited
sympathy to these patients without realizing the
damage they are doing.

After surgery, these patients are prone to be
apprehensive and fearful of their new status.
We make every attempt to bolster their morale
and, on the day that the colostomv is opened, we
explain that the first few times the colostomy
functions we are unable to predict whether the
stool will be well-formed, soft, or watery. We
state that if a waterv stool should occur and soil
the bedclothes, it is not cause for alarm or fear
that this condition will continue. We ask the
nurses to be extraordinarily helpful in keeping
these patients clean in order to avoid unneces-
sary embarrassments. Usually, the first move-
ment will be well-formed or soft. With the
advance warning we have given, the patient is
happily surprised and becomes quite satisfied
with his colostomy. After several days our pa-
tients are told that it would be well to start car-
ing for the colostomy themselves, since they will
want to be independent when they go home. It
is interesting to see how well most patients ac-
cept this assignment soon after surgery. We like
to impress upon our patients the fact that they
should not expect to have others care for their
colostomy when they are at home.

I must admit that there are healthy differences
of opinion concerning the patient’s care from this
point on. Breidenbach and Secor,2 in an excel-
lent paper published in the American Journal of
Surgery in January of this year, state that a
patient should be taught to irrigate his colostomy
about the tenth day after surgery. In this pro-
gram, we do not concur. We feel that a patient
will be in a much better position to irrigate and
to appreciate the value of irrigation after he has
learned more about the functioning of and care

of the colostomy before irrigations are started.
When our patients leave the hospital, they are
given a supply of dressings and are told exactly
how to take care of the colostomy. They are
advised to take tub baths and are told that a
soft wash cloth can be used directly on the
stoma. They are given a prescription for pare-
goric in case the bowels move too often and
are given some insight into the dietary regime.
This I will discuss subsequently. The patients
are told to report to the office at the end of two
weeks. At that time, they are interrogated in
detail as to the behavior of the colostomy. Not
infrequently, we have a patient who states that
his colostomy has given him very little trouble.
The bowel moves once a day, usually on arising
in the moring or just after breakfast. These
patients need very little further instruction. Ir-
rigation would serve only to complicate the life
of the patient and is totally unnecessary. The
other patients whose bowels move several times
a day or at erratic intervals are taught a very
simple method of irrigation. An Asepto syringe,
a catheter, and lubricant are all that are needed
in the way of equipment. We demonstrate var-
ious types of irrigating appliances, but most of
our patients are well satisfied with the simple
procedure. 1 am not surprised that many doctors
state that a certain method of irrigation, and that
alone, is the proper procedure. Nor am I sur-
prised when many patients come to me with
their ideas of the proper way to irrigate a colos-
tomy. The truth of the matter is that there are
many ways of doing it, some of which work well
for one patient while results are not the same for
others. If a patient can irrigate and empty his
colon in a period of thirty to forty-five minutes
and if he can remain clean for twenty-four to
forty-eight hours, this function is being per-
formed satisfactorily. The important point is
that the surgeon who performs the operation
should supervise the education of the patient.

There are many appliances on the market for
patients who have colostomies. We do not feel
that an appliance is necessary for an intelligent
and cooperative patient. If the bowel is emptied
well, with or without irrigation, a small piece of
gauze under an elastic abdominal support should
be all that is required. When a patient wears a
bag or a plastic pouch, it is quite obvious that
he is not doing well in emptying his bowel at
stated intervals. We have a few patients who,
in spite of good colostomy care, absolutely insist
on wearing a ring and plastic cover for their own
self-assurance. We do not feel that the point is
worth arguing. We discourage use of colostomv
belts, bags, domes, and other bulky appliances.

JANUARY 1958

17

The subject of diet is extremely important for
the patient with a colostomy. It is very easy
for such a patient to become a dietary cripple.
We do everything possible to prevent this occur-
rence. Our patients are told that they will be
able to eat essentially the same foods as they ate
before surgery. We sincerely believe that there
are verv few foods which influence the function
of the large bowel. We believe that the trans-
portation of feces in the colon is influenced more
by the neuromuscular mechanism, which de-
pends on bulk and fluid, and by the emotional
status of the patient than by any other factors.
Our patients are told to eat everything, but we
explain that they may find that one or more foods
will cause some trouble. If a patient decides that
his colon is functioning improperly because of
a certain food, it is well to omit that particular
item from the diet. In our experience, most
colostomy patients have one or two foods from
which they abstain, but, for the most part, the
diet is extremely liberal and all inclusive. It is
true that some foods, such as beans, cauliflower,
and cabbage produce more gas than others. This
is just as true in patients without colostomies.
Common sense should dictate that these foods
be avoided as much as possible. Highly spiced
foods may produce an increased amount of gas.
Each patient must decide whether this is true
in his particular case. The importance of restrict-

REFERENCES

1. Dinnick, T.: Origins and evolution of colostomy. Brit. J.

Surg. 22:142-154, 1934-35.

ing the diet in patients with colostomies has been
unnecessarily overemphasized in the past. It is
high time that this practice be discontinued. The
patient with a colostomy has been penalized
enough without being unnecessarily burdened
with a restricted diet.

This discussion would not be complete without
further comments on the value of colostomy
clubs. We are all cognizant of the value of
group therapy in emotional and other psychiatric
disturbances. The colostomy club acts as a group
therapy class. Patients with common problems
get together for discussion and to learn how best
to handle their individual problems. When a
person with a new colostomy sees other people
who are entirely rehabilitated and who are lead-
ing normal lives, it cannot help but raise his
morale. In St. Paul, we have a colostomy and
ileostomy club which has performed outstanding
service in visiting patients both pre- and post-
operatively and in helping during the period of
readjustment. I heartily recommend the forma-
tion of these clubs in all medical centers in the
country. The life of a patient with a colostomy
need not be a restricted and unhappy one. With
proper education and with the help of an under-
standing physician, these patients can lead rela-
tively normal lives. One need only to attend a
meeting of a colostomy club to appreciate the
accuracy of this statement.

2. Breidenbach, L., and Secor, S. M.: Proper handling of the
colostomy patient. Am. J. Surg. 93:50-56, 1957.

After abdominal hysterectomy, early feeding decreases the need for in-
travenously administered fluids but increases nausea, vomiting, distention, and
gas pains. Onlv 0.39 liters of intravenous fluids were given on the third post-
operative day to 38 patients fed a solid, high-protein diet immediately after
total abdominal hysterectomy, whereas administration of 0.89 liters was neces-
sary in 41 patients managed in the usual manner. Nausea and vomiting oc-
curred in 18 of the women fed the special diet but in only 8 of the controls.
Moderate or severe abdominal distention was observed in 3 of the control
group and 5 of the special diet group. Onlv 10 control subjects had moderate
or severe gas pains, whereas 15 patients fed immediately after operation had
such distress. More thorough preoperative explanation of the regimen to the
subjects might have led to better results, since some opposition to early feeding
expressed bv relatives and some of the nursing staff may have dismayed the
patients.

Joseph H. Pratt, Jr., M.D., and Glenn Cantrell, M.D., Mayo Clinic and Foundation, Roches-
ter, Minnesota. S. Clin. North America 37:1091-1099, 1957.

18

THE JOURNAL-LANCET

Comparative Clinical Pharmacodynamic
Evaluation of Newer Hypotensive Drugs

RUDOLPH E. FREMONT, M.D., F.A.C.P., F.A.C.C.
Brooklyn, New York

Although the cause of hypertension cannot
be established in the great majority of
patients with this malady, they all have in com-
mon an abnormal increase of the peripheral vas-
cular resistance at the arteriolar level. This is the
only one of the factors known to influence the
level of arterial blood pressure that is consistently
abnormal. Other factors— blood volume, cardiac
output, arterial elasticity, and blood viscosity-
become abnormal but not consistently and onlv in
complicated and advanced forms of hypertension.

There is considerable controversy concerning
the importance of humoral and neurogenic fac-
tors in relation to the increased peripheral vas-
cular resistance present in hypertension. So far.
however, onlv the neurogenic factor, manifested
by an excessive increase of the sympathetic tone,
can be modified sufficiently by therapeutic means
to lead to reversibility of the hypertension or
postponement of the organic sequelae.

Until recently, chemotherapy directed against
the excess activity of the sympathetic nervous
system was greatlv handicapped by the inade-
quacy and nonspecificity of the drugs available.
The dissatisfaction with the results of medical
therapy led, therefore, to rapid and widespread
acceptance of surgical therapy when sympa-
thectomy was shown to be effective in reducing
hypertension and in abolishing secondary symp-
toms and sequelae.

When eventually large statistics of surgically
treated patients became available, their compari-
son with adequate control observations revealed,
however, to quote Page, “a few brilliant succes-
ses, some patients definitely . . . benefited and
some not at all.”

A renewed chemotherapeutic attack upon hy-
pertension has been under way since the end of
the last war due to the discovery of a number
of drugs of sufficient potency and specificity to

rudolph e. fremont is chief of the Cardiovascular
j Section at Veterans Administration Hospital , Brook-
lyn, New York and clinical assistant professor of
medicine at the State University of New York, Down
State Medical School.

affect the hypertensive state both as produced
experimentally and as encountered in man. The
ever increasing number of these drugs, their
pronounced variation in chemical structure,
pharmacodynamic activity, and potency of both
specific and nonspecific character have brought
with them a similarly high variation in clinical
applicability. This often confusing and poten-
tially hazardous situation requires a critical ap-
praisal at frequent intervals. This is the reason
for the following review, which attempts a com-
parative clinical pharmacodynamic evaluation of
the most important antihypertensive drugs.

DEFINITION AND CLASSIFICATION

Hypotensive agents can be classified in a general
manner into those that influence the peripheral
resistance bv: (1) direct inhibition of the vaso-
motor center, ( 2 ) blocking of autonomic ganglia,
and (3) adrenergic blocking at peripheral sym-
pathetic nerve endings. Such classification is
however, misleading unless it is understood to
reflect merely the predominant action of a par-
ticular hypotensive agent. Many act simultane-
ously at different sites within the sympathetic
nervous system ( table 1 ) . Another matter of
terminology and inherent implication of action
deserves discussion. Much has been made until
verv recently of the differentiation between the
“sympatholytic” and the “adrenolytic” effects of
some of these hypotensive agents. The first sup-
posedly indicates a blocking of sympathetic nerve
activity, the last a blocking or neutralization of
circulating adrenergic substances, such as epi-
nephrine and norepinephrine. It has been dem-
onstrated conclusively that such differentiation
is artificial and that it merely reflects the predom-
inating activity of a hypotensive drug which, al-
most without exception, can be shown to have
complex activity. In general, the sympatholytic
action is less marked than the adrenolytic.

The broader term “adrenergic blockade” was,
therefore, recommended by Nickerson for the
description of the activity of these agents, and
it has found general acceptance. It is, however,
often used to describe the action of hypotensive

JANUARY 1958

19

TABLE 1

SITE AND DEGREE OF EFFECT OF HYPOTENSIVE AGENTS

Drug

Ganglionic

“ Sympatholytic ”

“Adrenolytic”

CNS

Humoral

Other

1 . Dibenamine

0

+

+ +

+ +

0

2. Piperoxan

0

0

+ +

+

0

3. DHE alkaloids

0

+ +

+

+

0

4a. Priscoline

0

+ +

+

+

0

b. Regitine

0

+

+ ( + )

( + )

0

5. Hydralazine

0

++

+

+

+

6a. TEA

+

b. C5

+ +

0

0

0

0

C. Co

+ + +

7. Thiophanium derivative

( + )

+

+

+

0

8. Veratrum alkaloids

0

0

0

p

0

Card?

9. Rauwolfia

0

0

0

+

0

drugs that decrease peripheral resistance bv
mechanisms other than adrenergic blockade.
Obviously, such terminology is again misleading
and should be abandoned in favor of the general
term of “hypotensive action.”

SITE OF EFFECT AND CHEMICAL STRUCTURE

Table 1 demonstrates the site of action of the
hypotensive drugs to be presently discussed.
Their degree of activity is characterized by the
use of symbols. A consideration of the chemical
structure and its relation to the pharmacologic
activity reveals striking differences both in chem-
ical structure and pharmacodynamic activity of
the drugs under consideration.

Dibenamine, one of the most potent and most
highly specific adrenergic blocking agents, is a
/3-haloalkvlamine related to the nitrogen mus-
tards. Related to it are its benzyl-methyl phe-
noxyethyl derivative ( Dibenzyline ) and piper-
oxan (Benodaine). The adrenergic blocking ac-
tivity of these drugs depends on the basic chemi-
cal structure /3-phenylethylamine (figure 1) which
they have in common. The specific adrenergic
blocking activity of these and related tertiary
amines presupposes a particular chemical reac-
tivity with the formation of highly active inter-
mediate compounds.

The next group of agents showing adrenergic
blocking action is made up of structurally com-
plex substances. They are obtained bv hydro-
genation of the three alkaloids contained in ergo-
toxine: namely, ergocornine, ergocristine and
ergokrvptine. This process of reduction increases
the adrenergic blocking effect of these alkaloids

and decreases at the same time their ability to
stimulate smooth muscle. These three alkaloids,
referred to subsequently as DHE alkaloids, have
in common a dimethylpyruvic acid, an amino
group, and proline as the protein molecule. Their
difference in adrenergic blocking activity appears
to be related to the difference in the type of
amino acid present in their structure.

However, this group, available for clinical use
under the name of Hydergine, does not exhibit
as exclusively an adrenergic blocking activity as
Dibenamine, since it shows also direct central
effect. This additional action was overlooked for
some time but is now well recognized as being
responsible to a considerable degree for the so-
called sympatholytic effect. The duration of ac-
tivity of these agents is moderate.

Another group of chemically related hypoten-
sive agents, consisting of Priscoline and Regitine,
exhibits mixed adrenergic blocking and central
activity. The chemical structure is basically that
of imidazoline and as such is related to histamine
(figure 2). This relationship is considered a
possible explanation for the many histamine-like
effects of Priscoline and Regitine.

There is some controversy as to whether Prisco-
line is more strongly sympatholytic or adrenoly-
tic. Species differences may account for the dis-
crepant data obtained in animal experiments. In
man, the direct depression of sympathetic nerve
activity appears more pronounced than the ad-
renolytic effect. In addition, a direct central in-
fluence is also often evident. The duration of
activity of Priscoline is quite short, though slight-
ly longer than that of piperoxan. Regitine dis-

20

THE JOURNAL-LANCET

plays a more pronounced adrenolytic action than
Priscoline and one of longer duration than piper-
oxan.

The next hypotensive agent of importance is
hydralazine, an abbreviation for 1-hydrazinoph-
thalozine, available clinically under the name of
Apresoline (figure 3). This drug shows mixed
activity with only very slight adrenolytic and
moderate sympatholytic activity. The main site
of its effect lies centrally, probably at the hypo-

H

N— ch

HC

HISTAMINE

N— CH-CH2-CH2-NH2

H,C

CH2— C

H

N-CHZ

n-ch2

N— C

H

, N — C H2

N — C H2

PRISCOLINE

REGITINE

Fig. 2. Chemical relationship of Priscoline and Regitine
to histamine.

0 - PHENYLETHYLAMINE
RADICAL

0 1 BEN AM I N E

Fig. 1. Chemical struc-
ture of Dibenamine, Di-
benzvline, and piperoxan
shown to be basically the
same as /3-phenvlethyla-
mine.

DIBENZYL I NE

PIPEROXAN
(933 F)

thalamic level. It appears further to be the onlv
hypotensive agent available which, according to
early and as yet inadequately confirmed reports,
blocks pherentasin, a humoral vasopressor sub-
stance demonstrated in cerebral extracts.

We come next to the ganglionic blocking group
of quaternary ammonium compounds, tetractlujl-
ammonium (TEA), pentamethonium (C5) and
hexamethonium (C6). Chemically, all three show
a striking relation to acetylcholine (figure 4).

It is suggested that the pharmacologic effect
of these agents which block both sympathetic
and parasympathetic activity at the ganglionic
level is due to interference with acetylcholine
activity. They are highly potent hypotensive
drugs, with potency weakest in TEA and most
marked in C6. Newer related compounds such
as pendiomid and pentolinium ( pentapyrrolidin-
ium) have been introduced recently into clinical
usage. The most promising is pentolinium tar-
trate marketed as Ansolvsen. This whole group
of agents will be referred to subsequently as the
methonium group.

Of entirely different chemical constitution is
Arfonad, a Thiophanium derivative. Pharmaco-
dynamically, it resembles TEA with its gangli-
onic blocking effect but differs from it by the
additional possession of moderate adrenergic-
blocking and central activity.

The next important group of hypotensive

JANUARY 1958

21

NH— NH2- HCL

Fig. 3. Chem-
ical structure of
hydralazine.

HYDRALAZINE

agents is derived from Veratrum viride. Several
alkaloids have been extracted, some in fairly
purified form. These alkaloids and even their
crystalline fractions are very complex com-
pounds. Chemically, some of them are esters,
others alkamines. The latter have been foun 1
to have sterol structures. Veriloid and protover-
atrines A and B, the latter under the name of
Veralba, are the two most extensively studied
fractions and have come into general clinical use.

Although Veratrum is an almost ancient drug,
the mechanism of its hypotensive action has been
elucidated only very recently. Because of the
bradycardia appearing in association with the
hypotension and because of the lack of any
demonstrable effect upon any part of the intact
sympathetic nervous system, it was thought for
a long time that the hypotensive activity of Vera-
trum alkaloids was in some manner tied up with
the Bezold reflex, whose afferent fibers arise in
the myocardium of the left ventricle. However,
cross circulation experiments in dogs in whom
head and body circulation were completely sep-
arated except for intact nervous communication
have shown that hypotension in the body can be
obtained when Veriloid or Protoveratrine is in-
jected into the head circulation alone and is then
not accompanied by bradycardia. Since in man
these agents similarly cause hypotension without
significant bradycardia, it seems reasonable to
assume a central (hypothalamic) site of action
in man. More recently, experimental work has
yielded data suggesting that the hypotensive
effect may be mediated via the carotid sinus.

Another hypotensive agent has recently been
introduced into clinical use and has become
established quickly as one of the most widely
applicable drugs for the treatment of hyperten-
sion. It is a mixture of alkaloids extracted from
the Indian plant Rauwolfia serpentina. They

have been broken down into several purified
fractions, of which reserpine was found to be one
of the most active. The site of action of this agent
appears to be limited to the hypothalamic region.
It does not block ganglia nor is it adrenolytic or
sympatholytic. The basic chemical structure of
reserpine alkaloids as well as many of the phar-
macodynamic effects resemble those of yohim-
bine, an ancient “sympatholytic” drug.

PHARMACODYNAMIC MANIFESTATIONS OF
HYPOTENSIVE ACTIVITY IN MAN

When pharmacologic and pharmacodynamic data
obtained with hypotensive agents in animal ex-
periments are applied to man, considerable diffi-
culties may be encountered. Most important are
those related to species differences. These are a
familiar phenomenon to the experimental phar-
macologist but tend to escape the attention of
the clinician who is too eager to translate phar-
macologic findings into clinical usage. These
considerations must prevail as long as basic ex-
perimental work in animals is required for the
study of drugs. In the instance of hypotensive
agents, this means the use of common carotid
occlusion, central vagal stimulation, stimulation
of the superior cervical ganglion of the cat, and
the nictitating membrane. However, certain pro-
cedures, such as cold exposure, the Valsalva ma-
neuver, tiltback and orthostatic maneuvers, and
the digital inspiratory constrictor response, allow
even in the moderately ill patient the observation
of vasopressor stimulation and the antagonism
by hypotensive drugs. Even the blocking effects
upon the action of adrenergic drugs, such as
epinephrine and norepinephrine, and of the cho-
linergic substances can be studied in man with
safety. Furthermore, newer methods of renal
clearance, cardiac and coronary sinus catheteri-
zation, and cerebral blood flow studies permit
the observation of the effect of hypotensive drugs
on the most vital compartments of the circula-
tion in man.

Thus, while data obtained with these methods
are not able to pinpoint all of the effects of hypo-
tensive agents in man, considerable information
is gained regarding the nature of the desired
specific action and any undesirable side effects
of these drugs.

There are, however, some fallacies inherent in

C2 h5

C2 H5

N— CL

CH3 / ch3

CH3 — ^N-(CH2)6-N^— CH3

ch3 ch3

Fig. 4. Chemical relation-
ship of TEA and hexa-
methoniuni to acetylcholine.

ACETYLCHOLINE TEA(ETAMON) C6 (HEXAMETHONIUM)

22

THE JOURNAL-LANCET

TABLE 2

COMPARATIVE VASOMOTOR RESPONSE TO HYPOTENSIVE AGENTS

Drug

Rate

Blood

Nor-

mals

pressure of
Hyper-
tensives

Orthostatic

hypotension

Cold Valsalva Tilthack

pressure overshoot overshoot

At

BP

tercn-l

PR

Epinephrine
BP PR

1. Dihenamine

A

zb

y

+ + +

TOTAL BLOCK

y

0

y

0

2. Piperoxan

A

zb

OA

0

0

y

A

y

zb

3. DHE alkaloids

V

oy

y

+

PARTIAL BLOCK

0

0

0

o

4. Priscolinc

A

zb

A

+

PARTIAL BLOCK

0

0

0

0

5. Hydralazine

A

y

y

+(+)

NEAR TOTAL BLOCK

y

A

y

0

6a. TEA

y

+

b. C5

A

y

y

+(+)

PARTIAL BLOCK

A

0

A

0

c. Cfi

y

+ +

7. Thiophanium

A

y

y

+(+)

Block

y

0

y

0

derivative

8. Veratrum

y

zb

+(+)

0 0 0

y

0

y

0

alkaloids

9. Rauwolfia

y

zb

y

0

0 0 0

0

-

0

-

testing the efficacy of these drugs in man. These
must be kept in mind when pharmacodynamic
data are used as a basis for therapeutic applica-
tion. First, the response of a given patient to a
drug administered intravenously in the course of
an acute experiment is not necessarily the same
as during a period of prolonged maintenance.
Developing tolerance on one side and cumula-
tive action and inherent side effects on the other
side may cause decisive differences that can
negate all predictability of a therapeutic res-
ponse based on preliminary testing. Second, even
in the acute experiment, the observed results of
vasomotor and general hemodynamic responses
to drugs that affect the sympathetic nervous sys-
tem are notoriously variable. This may be due in
any given instance to the degree of initial sym-
pathetic constrictor tone, the degree of organic
vascular disease present, the extent of blockade
achieved, and the resultant blood pressure re-
duction. It is with these limitations in mind that
we present in the following tables a survey of
the comparative vasomotor response to these hy-
potensive agents (table 2), their effect on renal
dynamics (table 3), and their over-all effect on
the circulation through various vascular compart-
ments ( table 4 ) .

It appears superfluous to elaborate on all the
data assembled and presented in these tables.
Most of them are self-explanatory. However,
those germane to a discussion of criteria for the
most desirable hypotensive drug deserve emphasis.

CRITERIA FOR DRUG SELECTION

The criteria to be fulfilled by the ideal hypoten-
sive drug may be listed as follows:

1. High specificity.

2. Blocking of strong vasopressor stimuli.

3. Significant reduction of blood pressure.

4. Favorable effect upon symptoms and signs
of hypertension.

5. No undue increase of pulse rate.

6. No impairment of circulation through kid-
ney, brain, and coronary arteries.

7. Easy, preferably oral, administration.

8. High therapeutic index.

In regard to specificity, if, under this term,
exclusive influence upon the sympathetic nervous
system with resultant reduction of the blood
pressure is understood, then no drug presently
available can be said to possess this character-

TABLE 3

COMPARATIVE EFFECT OF HYPOTENSIVE AGENTS ON
RENAL FUNCTION

Drug

Glomerular Renal

filtration blood flow

Filtration

factor

Urine

volume

1. Dihenamine

initiaiy initial

y

variable

-

2. DHE alkaloids

initiaiy initial

y

0

y

3a. Priscolinc
b. Regitine

y

y

4. Hydralazine

yy

A

y

A

5a. TEA

b. C5

c. Cfi

y

oy

variable

y

6. Thiophanium
derivative

y

y

—

y

7. Veratrum
alkaloids

y

y

—

y

8. Rauwolfia

zbD

zb

zb

-

D lor dog

JANUARY 1958

23

TABLE 4

COMPARATIVE OVER-ALL EFFECT OF HYPOTENSIVE AGENTS

ON

CIRCULATION THROUGH

VARIOUS VASCULAR

AREAS

Drug

Peripheral

Coronary

Renal

Cerebral

Splanchnic

1. Dibenamine

A

0

A

A

NH

2. DHE alkaloids

A

A

A

aa

A

3. Priscoline

A

A

D

OA

A

A

-

4. Hydralazine

A

A

A

—

5a. TEA

A

OA

NH

b. C5

A

OA

OA

AO

A

c. Ce

A

A

6. Thiophanium

A

—

A

±N

_

derivative

7. Veratrum

0

0

A

A

alkaloids

8. Rauwolfia

-

0

0

-

-

D for dog

N for normotensive man
H for hypertensive man

istic, with the possible exception of the Veratrum
and Ranwolfia groups.

The blocking of strong vasopressor stimuli and
significant reduction of the blood pressure are
interrelated. Table 2 demonstrates that those
drugs that, in a potent manner, block pressor
stimuli from which one likes to protect the over-
reacting hypertensive patient, usually cause mod-
erate to severe orthostatic hypotension. This
effect is not limited to the ganglionic blocking
agents hut holds for all drugs that show moder-
ate to marked hypotensive effects. It is so exces-
sive in the case of Dibenamine that this drug
cannot be used for the treatment of hypertension
and so pronounced in the case of the methonium
group that treatment must be administered with
utmost caution.

An attempt to select a drug that possesses the
desirable property of slowing rather than acceler-
ating the pulse rate yields only a few, the DHE,
Veratrum, and Rauwolfia alkaloids. In mean,
this effect is considerable only with the Rauwolfia
group and minimal and inconstant with the other
two. Fortunately, those hypotensive drugs in
clinical use that accelerate the heart rate do so
only rarely to an excessive degree.

Since of all circulatory compartments, the renal
circulation maintains the most intimate and in-
terdependent relationship to hypertension, there
is ample reason for careful evaluation of the
effect of hypotensive agents upon the dynamics
of the renal circulation. The ideal effect would
be one of increased renal blood flow regardless
of whether renal involvement plays a primary or
secondary role in hypertension. As evident from

table 3, only one drug, hydralazine, has been
demonstrated to possess this effect. All the other
potent hypotensive drugs tend to depress renal
function, all the more so the higher the initial
blood pressure and the more severely disturbed
the renal function is prior to treatment. This is
most pronounced in the malignant phase of hy-
pertension with uremia and least striking when
hypertension is moderate and renal function only
slightly disturbed.

Observations involving the prolonged use of
hydralazine have, however, shown that the in-
itially increased renal blood flow may eventually
return to normal levels. Similarly, the initial re-
duction of the renal blood flow produced by the
methonium group and protoveratrines tends also
to disappear with prolonged use. This may ex-
plain the occasional increase in urinarv output
and drop of blood urea nitrogen observed clini-
cally.

As regards the effect upon the other circula-
tory compartments, table 4 reveals no undue di-
rect effect of any of the hypotensive agents under
discussion upon the coronartj circulation. A few
have been shown in animals or man to be act-
ually able to increase coronary blood flow to a
slight degree. This is hardly of any clinical sig-
nificance. The effect upon the cardiac output has i
been studied in the case of several hypotensive
drugs. Some, like the DHE alkaloids and hydra-
lazine, tend to increase the cardiac output, the
first mainly by a centrally mediated increase of
the rate, the latter both by this means and poss-
ible direct stimulation of the myocardium. The
clinical significance of this is demonstrated by

24

THE JOURNAL-LANCET

the not infrequent occurrence of angina pectoris
with or without preceding tachycardia and even
of myocardial infarction in hypertensive patients
with coronary disease treated with hydralazine.

Other hypotensive drugs, such as the Veratrum
and the methonium groups, tend to decrease the
cardiac output. It is not certain whether this is
accomplished by direct depressive action upon
the myocardium, as has been held for a long
time in the case of Veratrum, or via splanchnic
pooling and resultant decrease of venous return,
as appears more recently documented for both
the methonium and Veratrum group. This effect
has actually proved of benefit to hypertensive
patients in acute left ventricular failure.

In general, however, any precipitous drop of
the blood pressure, particularly when associated
with an increase of the pulse rate, may precipi-
tate myocardial ischemia and even infarction.
Thus, where concern for the integrity of coronary
circulation is paramount, the use of drugs, such
as hydralazine, the methonium group, and Vera-
trum alkaloids, must be particularly circumspect.
The use of reserpine in combination with such
agents should prove particularly advantageous in
these circumstances by virtue of its ability to
slow the rate and also to decrease the need for
larger doses of the more potent hypotensive
drugs.

Regarding the cerebral circulation ( table 4 ) ,

fortunately, none of the drugs under discussion
decreases cerebral flow. Many decrease cerebral
resistance in line with the drop of the systemic
blood pressure, but, again, as in the case of the
hypertensive patient with coronary disease, the
one with cerebrovascular involvement must not
be subjected to precipitous reduction of the
blood pressure, since this is bound to lead to
severe decrease of cerebral blood flow.

Limited documentation is available regarding
the effect of hypotensive drugs upon the splanch-
nic circulation. Undoubtedly, it participates with
skin and muscle circulation to a considerable
degree in the general relaxation of the peripheral
vascular resistance, which is responsible for the
reduction of the blood pressure.

As regards administration, table 5 summarizes
data based, in addition to the basic pharmacody-
namic properties, also on such factors as the
speed of onset of activity, feasible route of ad-
ministration, speed of excretion, duration of ac-
tivity, cumulative effects, and development of
tolerance. Extensive and carefully conducted
clinical studies have shown that most of the hy-
potensive drugs now available leave much to be
desired in terms of ease of administration.

The clinical applicability is further compli-
cated by a variable incidence and degree of side
effects (table 6).

The latter are not limited to systemic toxicity

TABLE 5

CRITERIA FOR DESIRABLE CHARACTERISTICS OF HYPOTENSIVE DRUGS AND RELATIVE STANDING OF THOSE NOW IN USE

Improvement

Slowing

Unimpaired blood

Easy

High

Blocking of

of symptoms

of heart

flow

administration

tlxera-

Sped-

vasomotor

Reduction

and of

rate

Coro-

Cere-

Paren-

peutic

Drug

flcity

stimuli

of BP

hypertension

Renal

nary

hral

teral

Oral

index

1. Dibenamine

No

Marked

Marked

—

No

No

Yes

—

No

No

No

2. Dibenzyl ine

No

Slight

Slight

No

Yes

Fair

n tv

No

No

No

No2

4. DHE alkaloids No

Slight

Minimal

Minimal

Occas.

No

Yes

Yes

Yes

Yes

Yes

5. Priscoline

No

Slight

Minimal

No

Yes

Yes

Yes

Yes

Yes

Yes

r n

No

No

7. Hydralazine

No

Marked

Mod.

Yes

No

Incr.

Usually

Yes

Yes

Yes

Yes

8. Methonium

group

No

Marked

Marked

Yes

No

No

Yes'

Yes'

Yes

Fair

Fair

9. Arfonad

No

Mod

Mod.

No

No

—

—

Yes

No

Fair

10. Veratrum

alkaloids

Yes?

Slight

Mod.

Yes

Occas.

No

Yes1

Yes1

No

No

No

1 1 . Reserpine

Yes?

No

Slight

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

1Except with precipitous drop of blood pressure.

^Associated with hypertensive crisis occasionally induced by piperoxan.

JANUARY 1958

25

TABLE 6

CLINICAL

APPLICABILITY AND

SIDE EFFECTS OF

HYPOTENSIVE AGENTS

Peripheral

Hypertensive

Pheochromo-

Side effects

Drug

vascular disease

vascular disease

cytoma

Degree

Incidence

la.

Dibenamine

+

+

+ +

Severe

Freq.

b.

Dibenzyline

+ +

+ +

0

Mod.

Freq.

2.

Piperoxan

0

0

+ + +

Mod.

Freq.

3.

DHE alkaloids

+ +

+

0

Mild

Freq.

4a.

Priscoline

+ + +

0

Mod.

Freq.

b.

Regitine

+ ( + )

0

+++

Mild

Freq.

5.

Hydralazine

( + )

++

0

Mod.

Severe

Freq.

Occas.

6a.

TEA

( + )

(+)

+

Mod.

b.

C5

+

++

—

Mod.

Freq.

c.

C«

+ ( + )

+ H — h

—

Severe

7.

Thiophanium derivative

( + )

(+)

—

0

—

8.

Veratrum alkaloids

0

++

0

Mod.

Severe

Freq.

Occas.

9.

Rauwolfia

0

+(+)

0

Minimal

Occas.

but also frequently involve excesses of the in-
herent pharmacodynamic activity. Examples of
the first type are the occurrence of a lupus
erythematosus-like syndrome produced by the
prolonged use of large doses of hydralazine
and gastrointestinal intolerance observed with
Dibenzyline and Priscoline. Examples of the
second type are the unpredictable and, at times,
unavoidable peripheral vascular collapse follow-
ing the use of Veratrum drugs; the excessive cen-
tral stimulation by Dibenamine, resulting in de-
lirium and convulsion; unpleasant tremulousness
after use of DHE alkaloids; severe depression
occasionally seen with Rauwolfia; and accom-
modation paralysis noted with the methonium
group.

These side effects do not affect the clinical
applicability of these drugs in terms of their use-
fulness in peripheral vascular disease, hyperten-
sive cardiovascular disease, and hypertension
due to pheochromocytoma (table 6). Their re-
spective place in the management of these con-
ditions depends primarily on their site and de-
gree of pharmacodynamic activity as seen in
table 1. Thus, those drugs with markedly pre-
dominant adrenolytic action are best suited for
the diagnostic and therapeutic management of
crises due to a pheochromocytoma. Those with
relatively strong, if not exclusive, sympatholytic
action are most useful as peripheral vasodilators,
while the ganglionic blockers tend to be useful
only as hypotensive agents. Their predominant
effect upon the blood pressure makes their use

for the treatment of peripheral vascular disease
impracticable and often impossible even in nor-
motensive patients. They can be employed, how-
ever, on a short term basis for the diagnostic
evaluation of peripheral vascular conditions, such
as the presence or absence of peripheral vascular
spasm.

CONCLUSIONS

Evaluation of available hypotensive drugs in the
light of the pharmacodynamic and clinical ob-
servations makes it obvious that no single hypo-
tensive agent has yet been found able to fulfill
all criteria of desirability. A careful selection of
a combination of hypotensive drugs and the fre-
quent addition of drugs counteracting their side
effects are at present the best and only working
solutions for the management of all but the mild-
est forms of hypertension. Such a selective order
of hypotensive drugs is offered in table 7.

The choice is based on the consideration of all
basic pharmacodynamic data in animal and man
and the likely clinical response of patients in
various phases of hvpertensive vascular disease.
It is recommended as a systematic approach to
the medical management of hvpertension and,
as such, has proved of great practical usefulness
in our experience. It may well be modified as
better hypotensive drugs become available.

ADDENDUM

Since completion of this review, two new hvpo-
tensive drugs have become available, Ecolid

26

THE JOURNAL-LANCET

TABLE 7

SELECTION OK HYPOTENSIVE DRUGS FOR TREATMENT OF HYPERTENSION

Hypertensive

state

Initial Drug It

1

Additional drugs in order of choice

2 3

1. Mild, symptomatic

Reserpine

Usually

not

required

2. Mod., with grade 3
fundi

Reserpinc

Apresoline

Ansolysen

Protoveratrine

3. Moil, or severe, with
a. Card, failure
or

Reserpine

Ansolysen

Protoveratrine

Apresoline

h. Coronary insuff.
c. Renal insuff.

Reserpinc

Apresoline

Protoveratrine

Ansolysen

d. Cerebrovascular
insufficiency

Reserpine

Apresoline

Ansolysen

or Protoveratrine

4. Acute hypertensive
encephalopathy

i.v. Protoveratrine

or Ansolysen

or Apresoline

or Reserpine

5. Malignant phase
a. Incipient

Reserpine

Protoveratrine Ansolysen

Apresoline

b. Established
1 . renal insuff.

Reserpine

Apresoline

Protoveratrine

Ansolysen

2. card, insuff.

Reserpine

Ansolysen

Protoveratrine

Apresoline

( chlorisondamine dimethochloride ) and meca-
mvlamine, marketed as Inversine, a secondary
amine ( 3-methylaminoisocamphane hydrochlor-
ide). Both are potent ganglionic blocking agents
and, according to experimental and limited clini-

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Proc. Soc. Exper. Biol. & Med. 67:163, 1948.

Dl HYDROERGOT ALKALOIDS

19. Hartman, M., and Isler, H.: Chemische Konstitution und

pharmakologische Wirksamkeit von in 2- Stellung substituier-
ten Imidazoline. Arch, exper. Path. u. Pharmakol. 192:141,
1939.

20. Stoll, A., and Hoffman, A.: Die Alkaloide der Ergotoxin-

gmppe: Ergocristin, Ergokrvptin und Ergocormin. Helvet.

chem. acta 26:1570, 1943.

21. Rothlin, E.: Zur Pharmakologie der hydrierten naturlichen

Mutterkomalkaloide. Helvet. med. acta 2:48, 1944.

22. Bluntschli, H. J., and Goetz, R. H.: Effect of ergot deriva-
tives on circulation in man with special reference to 2 new
hydrogenated compounds. Am. Heart J. 35:873, 1948.

23. Bancroft, H., Konzett, H., and Swan, H. J. C.: Observa-
tions on action of hydrogenated alkaloids of ergotoxine group
on circulation in man. J. Physiol. 112:273, 1951.

PRJSCOLINE

24. Grimson, K. S., Reardon, M. J., Marzoni, F. A., and Hen-
drix, J. P. : Effects of Priscoline on peripheral vascular dis-

eases, hypertension and circulation in patients. Ann. Surg.
127:968, 1948.

25. Ahlquist, R. P., Huggins, R. A., and Woodbury, R. A.:
Pharmacology of benzylimidazoline (Priscol). J. Pharmacol.
& Exper. Therap. 89:271, 1947.

PIPEROXAN

26. Vleeschhouwer, G. R. de: Au sujet de Faction du diethyl-

JANUARY 1958

27

aminomethvl-3-benzodioxane ( F 883 ) et du piperido-methyl-
3-benzodioxane ( F 933 ) sur le systeme circulatoire. Arch,
internat. pharmacodyn. 50:251, 1935.

27. Bovet, D., and Simon, A.: Recherches sur l’activite sympa-
tholytique des derives de l’aminomethylbenzodioxane. Arch,
internat. pharmacodyn. 55:15, 1937.

28. Goldenberg, M., Snyder, C. H., and Aranow, H., Jr.: New
test for hypertension due to circulating epinephrine. J.A.M.A.
135:971, '1947.

REGITLNE

29. Grimson, K. S., Longino, F. H., Kernodle, C. E., and
O’Rear, H. B.: Treatment of patient with pheochromocytoma;
use of adrenolytic drug before and during operation. J.A.M.A.
140:1273, 1949.

30. Emlet, J. R., Grimson, K. S., Bell, D. M., and Orgain,

E. S.: Use of piperoxan and Regitine as routine tests in pa-

tients with hypertension. J.A.M.A. 146:1383, 1951.

hydralazine

31. Reubi, F.: Influence de quelques vasodilatateurs peripheriques
sur le flux sanguin renal. Helvet. med. acta 16:297, 1949.

32. Schroeder, 11. A.: Effect of 1-hvdrazinophthalozine in hyper-
tension. Circulation 5:28, 1949.

33. Gross, F., Druey, J., and Meier, R.: Eine neue Gruppe

Blutdrucksenkender Substanzen von besonderem Wirkungs-
charakter. Experientia, 6:19, 1950.

34. Freis, E. D., and Finnerty, F. A., Jr.: Suppression of vaso-
motor reflexes in man following 1-hydrazinophthalozine (C-
5968). Proc. Soc. Exper. Biol. & Med. 75:23, 1950.

35. Grimson, K. S., Cittum, J. R., and Metcalf, B. H.: Action
of 1-hydrazinophthalozine (C-5968) on vasomotor reflexes
and hypertension in dog and man. Federation Proc. 9:279,
1950. '

36. Taylor, R. D., Page, I. H., and Corcoran, A. C.: Hor-

monal neurogenic vasopressor mechanism. Arch. Int. Med.
88:1, 1951.

37. Taylor, R. D., Dustan, H. P., Corcoran, A. C., and Page,

I. H.: Evaluation of 1-hydrazinophthalozine ( “Apresoline” )

in treatment of hypertensive disease. Arch. Int. Med. 90:
734, 1952.

38. Moyer, J. H., Huggins, R. A., and Handley, C. A.: Fur-

ther cardiovascular and renal hemodynamic studies following
the administration of hydralazine and effect of ganglionic
blockade with hexamethonium on these responses. J. Phar-
macol. & Exper. Therap. 109:175, 1953.

39. Perry, H. M., Jr., and Schroeder, H. A.: Syndrome simu-
lating collagen disease caused by hydralazine (Apresoline).

J. A.M.A. 154:670, 1954.

METHONIUM GROUP

40. Lyons, R. H., and others: Effects of blockade of autonomic

ganglia in man with tetraethylammonium; preliminary obser-
vations on its clinical application. Am. J. Med. Sc. 213:315,
1947.

41. Moe, G. K., and others: Evaluation of vasomotor tone in ani-
mal and man bv means of tetraethylammonium. J. Lab. &
Clin. Med. 32:311, 1947.

42. Arnold, P., Goetz, R. H., and Rosenheim, M. L.: Effect of
pentamethonium on peripheral circulation. Lancet 2:408,
1949.

43. Burt, C. C., and Graham, A. J. P.: Pentamethonium and

hexamethonium iodide in investigation of peripheral vascular
disease and hypertension. Brit. M. J. 1:455, 1950.

44. Moe, G. K., and Freyburger, W. A.: Ganglionic blocking

agents. Pharmacol. Rev. 2:61, 1950.

45. Finnerty, F. A., Jr., and Freis, C. D.: Experimental and

clinical evaluation in man of hexamethonium (C6), a new
ganglionic agent. Circulation 2:828, 1950.

46. Smirk, F. H., and Alstad, K. S.: Treatment of arterial hy-
pertension by penta- and hexamethonium salts. Brit. Med. J.
1:1217, 1951.

47. Paton, W. D. M., and Zaimis, E. J.: Methonium compounds.
Pharmacol. Rev. 4:219, 1952.

48. Moyer, J. H., Huggins, R. A., Handley, C. A., and Mills,

L. C.: Effects of hexamethonium chloride on cardiovascular

and renal hemodynamics and on electrolyte excretion. J.
Pharmacol. & Exper. Therap. 106:157, 1952.

49. Rein, H. J., and Meier, R.: Phannakologische Untersuchun-

gen iiber Pendiomid, eine neuartige Substanz mit ganglien-
blockierender Wirkung. Schweiz, med. Wchnschr. 81:446,
1951.

50. Smirk. F. H.: Action of a new methonium compound in ar-
terial hypertension. Lancet 1:457, 1953.

51. Wien, R., and Mason, D. F. J.: Pharmacology of M&B

2050. Lancet 1:454, 1953.

52. Freis, E. D., Partenope, E. A., and Rose, J. C.: Penta-

pyrrolidinium (M&B 2050) in treatment of severe hyperten-
sion. Circulation 8:448, 1953.

53. Crumpton, C. W., Rowe, E. G., O’Brien, E., and Murphy,
O. R., Jr.: Effect of hexamethonium bromide upon coronary
flow, cardiac work and cardiac efficiency in nonnotensive and
renal hypertensive dogs. Circ. Res. 2:79, 1954.

54. Com insky , B., Prudy, J. R. K., Wheeler, H. O., Hays, R.
M., and Bradley, S. E.: “Splanchnic pooling’’ during hypo-
tensive action of hexamethonium bromide in dog. J. Clin.
Investigation 33:924, 1954.

55. Freis, E. D., Partenope, E. A., Lilienfeld, L. S., and

Rose, J. C.: Clinical appraisal of pentapyrrolidinium (M&

B 2050 ) in hypertensive patients. Circulation 9:540, 1954.

56. Maxwell, R. D. H., and Campbell, A. J. M.: New sym-

pathicolytic agents. Lancet 1:455, 1953.

57. Agrest, A., and Hoobler, S. W.: Long-term management

of hypertension with pentolinium tartrate (Ansolysen).
J.A.M.A. 157:999, 1955.

58. Smith, J. R., Agrest, A., and Hoobler, S. W.: Effect of

acute and chronic administration of pentolinium tartrate on
the blood pressure and cardiac output in hypertensive pa-
tients. Circulation 12:777, 1955.

ARFONAD

59. Sarnoff, S. J., Goodale, W. T., and Sarnoff, L. C.:
Graded reduction of arterial pressure in man by means of a
thiophanium derivative ( Ro 2-2222 ) ; preliminary observa-
tions of its effect in acute pulmonary edema. Circulation 6:
63, 1952.

VERATRUM ALKALOID

60. Krayer, O., and Acheson, G. H.: Pharmacology of veratrum
alkaloids. Physiol. Rev. 26:383, 1946.

61. Meilman, E., and Krayer, O.: Clinical studies on veratrum
alkaloids; action of protoveratrine and veratridine in hyper-
tension. Circulation 204, 1950.

62. Swiss, E. D., and Maison, G. L.: Site of cardiovascular ac-
tion of veratrum derivatives. J. Pharmacol. & Exper. Therap.
105:87, 1952.

63. Currens, J. H., Meyers, G. S., and White, P. D.: Use of

protoveratrine in treatment of hypertensive vascular disease.
Am. Heart J. 46:576, 1953.

RAUWOLFIA

64. Chopra, R. N., Gupta, J. C., and Mikherjee, B.: Pharma-
cological action of an alkaloid obtained from Rauwolfia serpen-
tina. Benth: preliminary note. Indian J. M. Research 21:261,
1933.

65. Wilkins, R. W.: New drug therapies in arterial hyperten-

sion. Ann. Int. Med. 37, 1144, 1952.

66. Wilkins, R. W., and Judson, W. E.: Lise of Rauwolfia ser-
pentina in hypertensive patients. New England J. Med. 248:
48, 1953.

67. Hughes, W. M., Moyer, J. H., and Daeschner, C. W.:
Parenteral reserpine in treatment of hypertensive emergencies.
Arch. Int. Med. 95:563, 1955.

ECOLID

68. Plummer, A. J., Trapold, J. H., Earl, A. E., and Max-
well, R. A.: Ganglionic blockade in a new bisquatemary

series including Ecolid ( chlorisondamine dimethochloride
(SU 3088). J. Pharmacol. & Exper. Therap. (cited bv
Grimson, K. S. J.A.M.A. 158:359, 1955.

69. Smirk, F. H., and Hamilton, M.: Action of Ecolid in man.
Brit. M. J. 1:319, 1956.

MEC AMYL AMINE

70. Moyer, J. H., and others: Drug therapy of hypertension; pre-
liminary observations on clinical use of mecamylamine, a
ganglionic block agent. Med. Rec. & Ann. 49:390, 1955.

71. Moyer, J. H., and others: Drug therapy (mecamylamine) of
hypertension; results with mecamylamine, completely absorbed
ganglionic blocking agent. Arch. Int. Med. 98:187, 1956.

28

THE JOURNAL-LANCET

Section on PAIN

Comments concerning this Section, criticisms, or suggestions for papers will he most
welcome. Physicians are cordially invited to submit articles pertaining to pain for
consideration. All inquiries and manuscripts should be sent to Dr. John S. Lundy,
102 Second Avenue Southwest, Rochester, Minnesota, or to the Editorial Depart-
ment, The Journal-Lancet, 84 South Tenth Street, Minneapolis, Minnesota.

Management of Tic Douloureux

O

CHARLES M. POSER, M.D.

Kansas City, Kansas

Pitfalls beset the path of the medical practi-
tioner in attempting to solve the problem of
facial pain. One of the reasons is that the area
which is usually affected is served by a number
of different nerves. Among them are the trigem-
inal, some of the upper cervical roots, the glos-
sopharyngeal, the great occipital, and, possibly,
some ill-understood contributions from the sym-
pathetic pathways.

With the great number of neuroanatomic struc-
tures possibly causing pain, go an even wider
variety of etiologic agents. In 1940, Glaser1 sug-
gested the following classification of the dis-
orders comprising what he called “atypical facial
neuralgia”:

1. Primary atypical facial neuralgia of un-
known etiology.

2. Facial neuralgia secondary to such causes
as herpes, abnormalities of the mandibular joints,
convulsive disorders, nuchal myositis, and so on.

3. Atypical facial neuralgia produced by
systemic diseases, such as allergy or psychoneu-
rosis.

4. Atypical facial neuralgia secondary to in-
fection or neoplasms in the region of the head
and neck.

Unfortunately, many patients who have gen-
uine atypical facial pain go from doctor to doc-
tor forever undiagnosed and overtreated. Re-

charles m. poser is assistant professor of experi-
mental neurology at the University of Kansas School
of Medicine, Kansas City, Kansas.

Read, in part, at a Symposium on Pain under di-
rection of the Department of Postgraduate Medical
Education, University of Kansas Medical Center, and
the University of Kansas City School of Dentistry,
March 6, 1957.

cause ignorance of the pathophysiologic mech-
anism of many painful syndromes still prevails,
their real distress is labeled a “psychosomatic
reaction.”

Nevertheless, among the host of painful con-
ditions affecting the face and its surrounding
structures, one syndrome is easily differentiated.
It is called “tic douloureux” or “trigeminal neu-
ralgia" and is manifested in the areas served by
the trigeminal nerve. The description of the tics
is so characteristic that the disease may be diag-
nosed by this means alone. The presence of the
tics coupled with a completely negative neuro-
logic examination is incontrovertible evidence
for true trigeminal neuralgia.

The distinguishing features of tic douloureux
are recurrent paroxysms of sharp, stabbing, and,
occasionally, burning or searing pain in the dis-
tribution of one or more of the sensory branches
of the trigeminal nerve. The single most out-
standing peculiarity of this disease, which makes
it easy to differentiate from other painful facial
conditions, is the paroxysmal nature of the at-
tacks. They are characterized by a lightning-
like suddenness of onset, short duration (from a
few seconds to a few minutes), rapid disappear-
ance of the pain, and completely pain-free inter-
vals between attacks. When the pain is in the
ascendant, it is excruciating and almost unbear-
able. In the colorful words of Harry Lee Parker,2
the sufferer from tic douloureux “looks miserable
and haggard, and he has every reason to be so,
for he has such a pain in his face that all the
devils out of Hell might be tearing at it.”

Trigeminal neuralgia is a disease of unknown
etiology, undetermined pathology, and unex-
plained phvsiology. It occurs most commonly in

JANUARY 1958

29

Section on PAIN

middle or late life and is slightly more common
in women. Usually, it is unilateral, but in 2 to
5 per cent of the cases, there is bilateral involve-
ment.3 The second division of the trigeminal
nerve is the most commonly involved; the first,
the least often affected.

Because the pain is so severe, tearing of the
eyes frequently accompanies it. The paroxysms
of pain may occur every few minutes or the
patient mav go for days, weeks, or months com-
pletely pain free. The pain may prevent him
from holding any job and even keep him from
carrying out any of his normal daily activities.
This is particularly true if so-called “trigger
points” or “trigger zones" are present. These
are areas of hypersensitivity, which, when touch-
ed or affected by motion, set off painful parox-
ysms. They are usually located on the face or
inside the mouth. When they are part of the
syndrome, it may be difficult or even impossible
for the patient to wash, shave, speak, or eat.
The face assumes a “masklike expression of . . .
immobility. There is in this expression the hope
of avoidance and the dread of recurrence.

Avicenna was the first to differentiate this dis-
ease about 1000 A. D., but the first clear deline-
ation of the syndrome is ascribed to Fehr and
Schmidt in the latter part of the seventeenth cen-
tury.4 Fothergill ' wrote a description of it in 1773
which remains unequalled to this day.

At times, tic douloureux affecting the third
division of the trigeminal nerve is difficult to
distinguish from glossopharyngeal neuralgia. This
disease is probably identical in nature with tri-
geminal neuralgia but affects the throat rather
than the face.3 Trigeminal neuralgia may occur
in combination with glossopharyngeal neuralgia3
as well as in combination with a tic-like neuralgia
of the great occipital nerve.6

The nathology of tic douloureux has never
been elicited, although theories abound. Its on-
set in late middle life seems to offer evidence
in favor of the theory that vasospastic ischemia
of the gasserian ganglion accounts for the symp-
toms in at least some cases. Since the disease
is never fatal and surgical removal of the gasser-
ian ganglion is not performed, histopathologic
studies are scarce. In the few that have been
done, no histologic changes have been shown
that would account for the disease.

A few conditions may mimic the syndrome and
must be distinguished from it. Most important
among these are acoustic neurinomas, which
occasionally produce tic douloureux. A history
of hearing loss, tinnitus, and findings of the neu-

rologic examination should help establish the
correct diagnosis and lead to the proper therapy.
Neurinomas of the gasserian ganglion will also,
on occasion, produce similar symptomatology,
but the finding of objective sensory changes in
the division of the trigeminal nerve should im-
mediately suggest such a diagnosis.

Harris7 has pointed out that on rare occasions,
sharp shooting pains in the face may occur
following thrombosis of the posterior inferior
cerebellar artery or of small perforating pontine
branches of the basilar artery. Here again, the
presence of objective neurologic signs should
establish the fact that the disease is not true tic
douloureux.

The pain of dental or periodontal disease is
rarely confused with trigeminal neuralgia of the
second or third division of the trigeminal nerve,
while migraine equivalents seldom are limited
to the anatomic distribution of the trigeminal
nerve. The pain of Costen’s syndrome is so clear-
ly related to movements of the jaw as to be un-
mistakable. Postherpetic trigeminal neuralgia is
easily diagnosed on the basis of previous herpetic
infection, and, although it is associated with
some paroxysmal pain, there is an almost con-
stant “background” of pain. A syndrome identi-
cal to tic douloureux occurs in multiple sclerosis,
but rarely is it the first symptom of the disease.
Therefore, here too the history, age of onset, and
the neurologic findings should help in establish-
ing the etiology of the manifestation.

From the preceding, it can be seen that in tic
douloureux, the neurologic examination is always
normal, and there are never objective signs in
the sensory distribution of the trigeminal nerve.
Should such signs be present, the diagnosis of
true trigeminal neuralgia can no longer be enter-
tained.

One of the few mitigating factors in this dis-
ease is that long-term and, occasionally, per-
manent remissions do occur. This, of course,
complicates the evaluation of any medical ther-
apy. Occasionally, if the history suggests that
an episode in the disease usually lasts a few days
or, perhaps, two or three weeks and then goes
into remission for a considerable period, it is
better to withhold therapy of any kind, provided
the patient understands his illness and agrees
with this decision.

The type of therapy to be employed must de-
pend on bow severely the patient is incapacitat-
ed, not only physically by the pain but also
psychologically by his dread of the next parox-
ysm. The physician may try purely medical

30

THE JOURNAL-LANCET

Section on PAIN

therapy if attacks are infrequent or simply inter-
fere with household duties, whereas, if the pa-
tient’s employment is in jeopardy, he may find
injection or early operation necessary. The pa-
tient’s attitude toward his illness as well as the
extent, type, and success of previous therapeutic
procedures are important considerations.

Little short of injecting the offending division
can be done for the patient during the actual
paroxysm of pain. However, the paroxysm is
usually of such short duration as to make this
procedure of questionable value. If possible,
narcotics should not be used, since, in a disease
such as this, with frequent recurrences and in
which the fear of the recurrent attack is so prom-
inent, the risks of iatrogenic addiction are serious.
The inhalation of trichlorethylene every two or
three hours may give transient relief of the acute
attack.8 In attacks of moderate severity, aspirin
and codeine may be of some help.

For longer term therapy, intramuscular injec-
tions of cyanocobalamin (vitamin B^) have
relieved paroxysmal attacks in 50 to 80 per cent
of the patients.9 There are various ways of ad-
ministering this treatment, a common way being
the daily injection of 1 cc. of cyanocobalamin
containing 1,000 /.ig. per cc. for a period of ten
or twelve days. Needless to say, it is difficult to
evaluate the actual value of the therapy against
the possibility of a spontaneous remission. Evi-
dence seems to suggest that these injections may
indeed be helpful. Certainly, this simple, harm-
less method of treatment should be made avail-
able to all patients with tic douloureux.

The intravenous injection of stilbamidine ise-
thionate lias also been recommended in the treat-
ment of this condition.10 The potential toxicity of
this drug, the long period necessary before eval-
uation of results is possible, the difficulties in-
herent in continuous and repeated intravenous
therapy, and the large percentage of patients
who complain of the burning paresthesia result-
ing from the characteristic neuropathy of the
trigeminal nerve make this type of therapy of
doubtful value.

Oral administration of various vitamin prepar-
ations, including cyanocobalamin has had no
effect. Injection of the trigger zones with local
anesthetics has been ineffective in most instances.

A different form of therapy consists of the in-
jection of either local anesthetic agents, such as
procaine, or of absolute alcohol into the gasserian
. ganglion or into whichever sensory branch is
| affected. Injection of alcohol into the ganglion
was first proposed by Hartel11 in 1912. Harris12

reviewed his experience and reported extremely
satisfactory results with this method in 1,433
cases. However, the occasional resultant devast-
ating paralysis of cranial nerves has deterred
most neurosurgeons from using this method. Jae-
ger18 recently proposed injecting boiling water
into the gasserian ganglion, claiming that it was
effective in relieving tic douloureux in 98 per
cent of his patients. It has none of the dangers of
alcohol injection and is, as far as he has been
able to determine from his follow-up studies,
capable of producing complete cure.

A simpler and more popular form of therapy
has been the injection of the different sensory
branches of the trigeminal nerve at the periphery.
The first division is easily accessible at the supra-
orbital notch; the second, with some practice and
experience, can be injected through the infra-
orbital foramen; while the third division may be
injected at the mandibular foramen. If relief and
an anesthetic zone are obtained with procaine,
the needle is left in place and absolute alcohol
is then injected into the nerve. This, of course,
results in an area of anesthesia corresponding to
the area of distribution of the affected sensory
branch.

Alcohol injection remains an eminently satis-
factory means of managing tic douloureux even
though the results are rarely permanent. Peet
and Schneider14 reported that 74 per cent of their
patients obtained relief for less than two months,
and only 15 per cent were relieved for more than
one year. The alcohol injection can be perform-
ed as an office procedure and may naturally have
to be repeated on several occasions.

Because of the close association and connec-
tions with other nerves in the area, it has been
suggested that relief may be obtained by injec-
tion of other nerves. Thus, Wyburn-Mason1"’ ob-
tained relief in 56 patients with tic douloureux
by alcohol injection of the greater auricular
nerve. Crue and his co-workers Ui reported good
results by injecting alcohol into the great occipi-
tal nerve.

The value of these different tvpes of injections
must once more be viewed in relation to the
possibility of spontaneous remission in this dis-
ease. In addition, the possibility exists that al-
most any procedure might be useful as long as
the cycle of the paroxysmal attack is interrupted.
This is known to take place in the treatment of
migraine, which comes in cycles similar to those
encountered in tic douloureux. Since some
authors have postulated the establishment of
“reverberating circuits” or “self-contained eir-

JANUARY 1958

31

Section oh PAI N

cuits' in the thalamus in cases of severe pain,
such as tic douloureux, the interruption of such
a circuit by a nonspecific procedure might ex-
plain the temporary relief in the same manner as
the fact that root section may not necessarily
lead to permanent relief of the disease.

Surgical intervention is probably the best es-
tablished type of therapy for this condition. It
is almost predictable that the great majority of
patients with tic douloureux eventually require
surgery to achieve complete lasting relief.

A variety of surgical approaches to this prob-
lem were used17 until Spiller and Frazier18 intro-
duced the modern operation, which consisted of
sectioning the sensory roots between the gang-
lion and the pons. Later, this operation was
further refined by the introduction of differen-
tial root section, so that anesthesia would be
restricted only to the affected area. The results
of this type of operation are unfortunately not
entirelv satisfactory. Even though the mortality
varies between 0.5 and 1.6 per cent, postopera-
tive complications include keratitis in 5 to 15
per cent, facial paralysis in 2 to 6 per cent, and
residual paresthesia develops in approximately
half of the patients.9 The latter complication
frequently becomes the most objectionable, and
many patients complain bitterly of the constant
and painful “numbness” which has replaced the
occasional attacks of pain. In one large series,14
severe trigeminal pain recurred in 14 per cent
of patients upon whom operations were per-
formed.

A more recent procedure, introduced by Taarn-
liPj19 in 1952, consists of decompression of the
posterior root by simply opening the dural
sheath. This operation has the advantage of
not producing unpleasant postoperative pares-
thesia. Relief is obtained in a considerable num-
ber of patients. An added advantage is that post-
terior root section can always be resorted to if
the trigeminal neuralgia recurs. This operation

REFERENCES

1. Glaser, M. A.: Atypical facial neuralgia. Arch. Int. Med.
65:340, 1940.

2. Parker, H. L.: Clinical Studies in Neurology. Springfield,
Illinois: Charles C Thomas, 1956.

3. Brzustowicz, R. J.: Combined trigeminal and glossopharyn-
geal neuralgia. Neurology 5:1, 1955.

4. Lewy, F. H.: First authentic case of major trigeminal neural-
gia. Ann. M. Hist. N.S. 10:247, 1938.

5. Fothergill, J.: Cited by Crawford and Walker.17

6. Skillfrn, P. G.: Great occipital-trigeminus syndrome as re-

vealed bv induction of block. Arch. Neurol. & Psvchiat. 72:
335, 1954.

7. Harris, W.: Rare forms of paroxysmal trigeminal neuralgia
and their relation to disseminated sclerosis. Brit. M. J. 2:1015,
1950.

8. Glaser, M. A.: Treatment of trigeminal neuralgia with tri-
chloroethylene. J.A.M.A. 96:916, 1931.

has gained considerably in popularity in this
country in recent years.

Trigeminal tractotomy in the brain stem, in-
troduced by Sjoqvist20 in 1938, is a rather formid-
able procedure. The results are not materially
better than those gained in other procedures
and do not justify the risks of this operation.

Compression rather than decompression of the
gasserian ganglion proposed by Shelden,21 simple
exposure of the ganglion with production of hy-
peremia as practiced by Stender,22 electrocoagu-
lation of the gasserian ganglion used by Kirsch-
ner,23 and section of the greater auricular nerve
advocated by Wybum-Mason15 have all been
used to limited extent with various degrees of
success and are still in the process of evaluation.

CONCLUSIONS

The proper management of the patient with
trigeminal neuralgia depends upon the patient’s
attitude towards his illness, the degree of severitv
of the disease in terms of discomfort and disabil-
ity, and the amount and extent of previous treat-
ment.

It is advisable to suggest a course of medical
therapy, that is, cyanocobalamin injections, to
the patient whose tic occurs at infrequent inter-
vals and does not materiallv interfere with his
normal activities. Alcohol injections of the offend-
ing branch should always precede surgical in-
tervention, but endless repetitions of this pro-
cedure rapidly reach the point of diminishing
returns. Effective surgical therapv in a patient
who has been adequately prepared for possible
complications of the operation, suggested at the
proper time in the course of the management,
will result in complete rehabilitation of the great
majority of severelv disabled patients.

There is no doubt that in most cases of tic
douloureux, patients should be prepared for
eventual surgical relief, since medical therapy is,
in most instances, of onlv temporary value.

9. Farmer, T. W.: Treatment of disorders involving the cranial
and peripheral nerves, in Modem Therapy in Neurology,
edited bv F. M. Forster. St. Louis: C. V. Mosbv Co., 1957.

10. Smith, G. W., and Miller, J. M.: Relief of tic douloureux
with stilbamidine. Ann. Int. Med. 38:335, 1953.

11. Hartel, F.: Die Leitungsaniisthesie und Injectionsbehandlung
des Ganglion Gasseri und der Trigeminusstamme. Arch. klin.
chir. 100:193, 1912.

12. Harris, W.: Analysis of 1,433 cases of paroxysmal trigeminal
neuralgia (trigeminal tic) and the end result of gasserian
alcohol injection. Brain 63:209, 1940.

13. Jaeger, R.: Permanent relief of tic douloureux by gasserian
injection of hot water. Arch. Neurol. Psvchiat. 77:1, 1957.

14. Peet, M. M., and Schneider, R. C.: Trigeminal neuralgia,
review of 689 ciises with follow-up study on 65 per cent of
group. J. Neurosurg. 9:367, 1952.

15. Wyburn-Mason, R.: Nature of tic douloureux; treatment by

32

THE JOURNAL-LANCET

Section on PAIN

alcohol block or section of great auricular nerve. Brit. M. J.
2:119, 1953.

16. Crue, B. L., Shelden, C. II., Pudenz, R. H., and Fresh-
water, D. B.: Observations on pain and trigger mechanism
in trigeminal neuralgia. Neurology 6:196, 1956.

17. Crawford, J. V., and Walker, A. E.: Surgery for pain, in:
A history of Neurological Surgery, edited by A. E. Walker.
Baltimore: Williams & Wilkens, Co., 19.51.

18. Spiller, W. G., and Frazier, C. H.: Division of sensory
root of trigeminus for relief of tic douloureux. Univ. Penn-
sylvania. M. Bull. 1-1:342, 1901.

19. Taarnh0j, P.: Decompression of trigeminal root and poster-

ior part of ganglion as treatment in trigeminal neuralgia. J.
Neurosurg. 9:288, 1952.

20. Sjoqvist, O.: Studies on pain conduction in trigeminal nerve;
contribution to surgical treatment of facial pain. Acta psychiat.
et neurol. (supp). 17:1, 1938.

21. Shelden, C. H., Pudenz, R. H., Freshwater, D. B., and

Crue, B. L.: Compression rather than decompression for

trigeminal neuralgia. J. Neurosurg. 12:123, 1955.

22. Stender, A.: “Gangliolysis” for surgical treatment of tri-

geminal neuralgia. J. Neurosurg. 11:333, 1954.

23. Kirschnf.r, M.: Die Punktionstechnik und die Elektrokoagu-
lation des Ganglion Gasseri; liber “gezielte” Operationen.
Arch. klin. Chir. 176:581, 1933.

Book Reviews on Pain

INTRODUCTION TO ANESTHESIA: THE PRIN-

CIPLES OF SAFE PRACTICE, by Robert D. Dripps,
M.D., professor and chairman, department of anes-
thesiology, Schools of Medicine, University of Penn-
sylvania and anesthetist, Hospital of the University of
Pennsylvania, Philadelphia; James E. Eckenhoff,
M.D., professor of anesthesiology, Schools of Medi-
cine, University of Pennsylvania and anesthetist, Hos-
pital of the University of Pennsylvania, Philadelphia;
and Leroy D. Vandam, M.D., clinical professor of
anesthesia, Harvard Medical School and director of
anesthesia, Peter Bent Brigham Hospital, Boston, 1957.
Philadelphia and London: W. B. Saunders Co., 266
pages.

All the authors of this work are well known and are
persons of authority in the field. What they have to
say represents accepted sound opinion. They cover the
field of anesthesia rather well, and they have included
useful information on the management of narcotic poi-
soning. They have made use of the most difficult but
most commendable literary technic of saying much in
few words, a technic which calls for a high degree of
accuracy. This requirement they have successfully sat-
isfied.

The book is printed on good paper, is easily read, and
is fairly well indexed. It is pleasant to come upon a
book as well done as this one. Anvone who is interested
in anesthesia should acquire the book.

John S. Lundy, M.D.

•

ANATOMIES OF PAIN, by K. D. Keele, M.D.,
F.R.C.P., 1957. Springfield/ Illinois: Charles C

Thomas, 206 pages. $5.50.

This book should become a classic and very likely it
will. Seldom does the reader experience such genuine
pleasure and even excitement from a book as are pro-
vided by this one. The work both stimulates thought
and enlarges one’s understanding of the ancient problem
of pain. The book would add greatly to the knowledge,
practical and cultural, of anyone interested in the sub-
ject of pain.

In his prefatory remarks, the author wisely observes,
“There appears to exist a widespread conviction that,
owing to the technical advances of the last century,
nothing of value can have existed previously that can
cast anv useful or revealing light on our present prob-
lems. The result is that historical introductions rarely

press further into the past than to a vaguely defined
‘Victorian era;’ and often with imperfect comprehension
even this far. A case in point occurs in a comprehensive
current work on the subject of pain, which by attrib-
uting the discovery of the spino-thalamic tract to Spiller
in 1905, ignores some fifty years of significant previous
work on this subject. To ignore the time dimension of
any problem is to risk misunderstanding it. Particularly
is this so if, as with regard to Pain, it involves neglect of
the keenest and most brilliant thinkers the world has
known.

“It is only of recent years that Pain itself has emerged
as a problem in its own right. Yet it has received spe-
cial attention as part of disease from the earliest dawn
of civilization. It is the purpose of this book to show
how the changing ideas on the anatomical and physio-
logical basis of Pain have flowed as a continuous process
from the most ancient medicine until the present day.
To attempt this is not to attempt a complete history of
the subject, but only to trace the growth of anatomy and
physiological concepts which lie, often unconsciously, at
the roots of our present ideas. To achieve such an in-
tegration I have necessarily been selective of those
writers whose works are for the most part well known,
for their influence has been greatest. Though authorities
have been omitted whose names rightly carry much
honor in the history of medicine, I have included all
those I have found who made significant contributions
to the process of the evolution of the subject.

“It is my own conviction that ‘right thinking’ is an
impersonal mode of mental activity in the Buddhist
sense; and that thinkers like Aristotle or Leonardo da
Vinci achieve exquisitely intimate interpretations of ob-
served phenomena, outstripping humbler thinkers, when-
ever they are born. However, one of the clearest lessons
to be learned from such a survey is that it is not enough
to have the right ideas; if they are to be fruitful of
results, thev must be produced at the right time, when
there is sufficient contextual background to support them.
It was just this failure of the intellectual milieu of his
dav that gave Leonardo’s right ideas such poor fruit,
leaving him in so manv fields merely the ‘anticipator’
rather than the recognized ‘discoverer.’

“In this book there will be found a story of anticipa-
tions needing firmer ground to raise them to discoveries.
Some have achieved such status already; others await it.

( Continued on page 34 )

JANUARY 1958

33

Editorial

A COMMON PAIN AND AN
UNCOMMON PROBLEM

Among the many common pains which may
visit the head, tic douloureux is one of the
most severe. This pain is so disabling that any-
thing which can be done to alleviate it is emi-
nently worth while. In fact, this type of pain is
so stubborn that the subject itself never becomes
old. It is treated in this issue by Dr. Charles M.
Poser under the title of “The Management of Tic
Douloureux.”

In the October 1957 issue of the Section of
Pain, I pointed out that I had been able, by
means of the combined use of several new agents,
to develop a plan to assist those who are doing
cardiac catheterization in children too young to
cooperate. Mv experience at that time was not
very broad. It still is not too extensive, but I
did describe in more detail in the November
1957 issue of the Journal of American Association
of Nurse Anesthetists' how this was managed.
Much more detailed instructions having to do
with this problem will appear soon, I hope, in
the Journal of the American Medical Associa-
tion.-

The present editorial was written on Decem-
ber 11, 1957. To that date I had carried out the

REFERENCES

1. Lundy, J. S.: New Methods for the conquest of pain through
use of antagonists and a new management of analgesia-
amnesia for cardiac catheterization in children too young to
cooperate. J. Am. A. Nurse Anesthetists. 25:221, 1957.

procedure for 34 patients, and, in general, the
method has been very satisfactory. I am in the
process of making it easier to measure the dose
of the drugs required. One drug, alphaprodine
hydrochloride (Nisentil hydrochloride) was sup-
plied by the manufacturer in the proportion of
60 mg. to the cubic centimeter of solution, a pro-
portion which made it almost impossible to mea-
sure a dose that would be minute enough to ad-
minister to a small baby. The proportion of this
agent to its solution will be corrected in the fu-
ture, I am sure.

As for the procedure itself, I have also used
it for two or three patients who were to under-
go examination of the eyes. It permitted ex-
amination adequate for arrival at a diagnosis-
something which has been difficult heretofore.

I think it is worth repeating that sometimes
better results can be obtained with drugs which
produce only analgesia and amnesia than with
drugs used in a dose large enough to produce
anesthesia. Cyanotic patients who have under-
gone cardiac catheterization have ranged from
15 months to 14 years and from 15 to 90 lb.
There may be other uses for this particular
method, but thus far we have not tried others.
The editor would appreciate comment about
other methods of managing these small children
during the diagnostic maneuver concerned.

John S. Lundy, M.D.

2. Lundy, J. S.: Method of producing amnesia-analgesia for

management of children too young to co-operate undergoing
cardiac catheterization and other procedures. J.A.M.A. (In
press. )

BOOK REVIEWS

( Continued from page 33 )

Perhaps one of the most topical of such anticipations is
the concept of the sensorium commune, which, far from
being an idea of our Victorian ancestors (as stated in a
current medical journal), is traceable back to the most
ancient thinkers on the nature of sensation, and now ap-
pears due for rebirth.

“It is my hope that present-day workers on Pain will
find in these Anatomies of Pain a useful background to
the problem, and possibly some still fertile seeds from
the past worthy of germination.

“To avoid the manifest risk of errors inherent in para-
phrasing views of ancient authorities, 1 have freely
quoted from their works. This however does not obviate
the erroneous significance which may be attached, for
example, to Aristotle’s often quoted description of pain
as a ‘passion of the soul,’ which words cannot be intel-
ligible without some background of Aristotelian physi-

ology. I have therefore endeavored to introduce each
authority’s views on pain with a sketch of his concept of
the basis of sensation sufficient to render the quotations
comprehensible.

“It has been my endeavor to render these accounts as
objective as possible in all chapters, with the exception
of the last, in which I have allowed myself to express
a more personal interpretation of the present anatomy
of pain.”

It is fascinating indeed to be taken back oxer the years
on a scientific Pegasus in a sort of guided tour of the
various anatomic and physiologic monuments to signifi-
cant thought in the understanding of pain mechanisms.

The book is printed on good paper and can be easily
read. It contains two indices — one on subjects and one
on personal names. Each chapter is well documented
with a bibliography. In sum, this book is a magnificent
contribution to the literature on pain.

John S. Lundy, M.D.

34

THE JOURNAL-LANCET

Section on PAIN

Current Literature on Pain

ANALGESICS AND THEIR ANTAGONISTS: SOME
STERIC AND CHEMICAL CONSIDERATIONS.
PART III. THE INFLUENCE OF THE BASIC
CROUP ON THE BIOLOGICAL RESPONSE, by
A. H. Beckett, A. F. Casy, and N. J. Harper: j.
Pharm. & Pharmacol. 8:874-884, 1956.

“Elsewhere the thesis was advanced that the basic group
of the molecule influenced analgesic activity and evidence
, was adduced in support. In morphine-type compounds,
a gradual transition from analgesic to anti-analgesic activ-
ity occurred as the group was changed from N-mcthyl
to N-ethyl, N-n-propyl and N-allyl .... It seems rea-
sonable to assume that the mechanism of action of an
! analgesic antagonist involves competition with an anal-
1 gesic for the ‘analgesic receptor site,’ but ‘fit’ at the re-
ceptor surface does not of necessity mediate an analgesic
response ....

“The hypothesis is advanced that analgesics and their
j antagonists undergo a similar chemical reaction subse-
quent to adsorption, the rate constant for the former be-
ing very much greater than that for the latter. Oxidative
dealkylation to produce nor-compounds is presumed to
be the first step in the reaction sequence leading to anal-
gesia. Nor-morphine has been shown to have a greater
I analgesic activity than morphine upon intracisternal in-
j jection into mice.”

jl From John S. Lundy and Fi.orence A. McQuillen: Anesthesia
1 Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 19. Copyright by John S. Lundy.

FATALITIES FOLLOWING TOPICAL APPLICATION
OF LOCAL ANESTHETICS TO MUCOUS MEM-
BRANES, by J. Adriani and D. Campbell: |.A.M.A.

162:1527-1530, 1956.

j “It is surprising that many physicians are unaware of the
hazards of local anesthesia. The pioneers in this field
recognized and emphasized the pitfalls that residt from
the misuse of local anesthetic drugs .... Accurate
statistics on the frequency of untoward reactions and
j fatalities due to local anesthetics are not available, be-
cause few such mishaps are reported. We are familiar
with 10 unreported fatalities in a 15-year period in this
institution [Charity Hospital, New Orleans] caused by
the topical application of tetracaine to mucous surfaces
| for endoscopic procedures ....

“It is the intent of this report to emphasize the extreme
potency and relative frecpiency of toxic effects from tet-
racaine and not to incriminate the drug as a lethal sub-
stance that should be discarded .... The major dis-
tinction between reactions due to tetracaine and those of
the other aforementioned drugs has been the absence of
convulsions and the abrupt opset of syncope. The inter-
val between the onset of symptoms and the moment of
the fatal termination was brief .... The incidence of
l reactions with use of tetracaine by other routes has been
considerably less than with the topical route ....

“Rapid absorption has been presumed as the cause,
but data in support of this contention have not been
available. Studies of blood levels of tetracaine indicate
that this occurs and at a more rapid rate than has been
supposed. A quantity of drug that results in no detect-
j able blood level when infiltrated subcutaneously gives
j levels when applied topically that are equal to one-third
to one-half of those after intravenous injection. The un-

toward responses are due to the rapid passage of the
drug from the site of application into the systemic circu-
lation. The absorption from mucous membranes is far
more rapid than clinicians have realized and simulates
intravenous administration. Study of the fatalities that
have occurred indicates that the cause of death is over-
dosage from rapid absorption.”

From John S. Lundy and Florence A. McQuillen: Anesthesia

Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 4. Copyright by John S. Lundy.

CORTISONE AND ANESTHESIA, by S. W. Corens:

J. Am. A. Nurse Anesthetists 24:259-264, 1956.

“Evidence exists to indicate that with more prolonged
administration of cortisone, suppression of adrenal cor-
tical function may persist for as long as 3 to 6 months
after the use of the hormone is discontinued .... The
patient may show evidences of adrenal insufficiency at
induction of anesthesia .... during the course of sur-
gery or in the immediate postoperative period. The first
and possibly only evidence of acute adrenal insufficiency
is otherwsie unexplainable cardiovascular collapse with
shock, tachycardia, pallor, etc

“The pituitary-adrenal interrelationship .... is al-
tered by the exogenous administration of cortisone so
that as a result you may get adrenal atrophy and insuf-
ficiency. That with the stress of anesthesia and surgery,
adrenal response may be inadequate and you may get
collapse, shock and death. In view of the ever increasing
number of individuals who are and will be receiving
cortisone and may have potential adrenal insufficiency,
it is important that anesthesiologists and surgeons be
aware of the dangers and be prepared to handle any
emergency situation that may arise in this regard.”

From Lundy, John S., and McQuillen, Florence A: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 73. Copyright by John S. Lundy.

•

THE ASSESSMENT OF THE CARDIAC PATIENT

FOR ANAESTHESIA, by A. J. W. Beard and J. F.

Goodwin: Brit. J. Anaesth. 28:557-568, 1956.

“Patients with cardiac disorders present the anaesthetist
with three main problems which are related to ( 1 ) the
operation itself, (2) the ability of the patient to with-
stand operation or any of its complications, and (3) the
selection of the anaesthetic agent and technique ....
A close rapport between anaesthetist and surgeon, and
their joint understanding of the physiopathologv of heart
disease makes for greater safety ....

“The cardiovascular state may be such that even an
urgent condition such as an operable neoplasm must re-
main untreated, but this is unusual, as, given time for
treatment of such conditions as congestive heart failure
or for the healing of a recent cardiac infarction, surgery
can often be carried through with little increased risk.
The control of cardiac rhythm and rate, the correction of
sodium and water retention, the treatment of anaemia,
the prevention of pulmonary infections, and weight re-
duction in obesity can so change the picture as to allow
the completion of even radical surgery ....

“Hvpoxia is the greatest danger to which the cardiac
patient is exposed during surgical operation. It is often
associated with other pathological conditions, such as
heart failure or hypotension, either as cause or effect.

JANUARY 1958

35

Section on PAIN

Hypoxia must therefore be considered in relation to such
states rather than as an isolated condition ....

“Ordinarily hypoxia is associated with carbon dioxide
retention which in moderate excess causes tachycardia;
gross carbon dioxide excess, however, impairs the con-
duction in the bundle of His, producing heart block and
slow ventricular rate. Furthermore, carbon dioxide re-
tention increases cardiac irritability and, especially in the
presence of cyclopropane or chloroform, cardiac irregu-
larity may be so gross as to impair the circulation ....

“Hypoxia may also result from anaemia. The danger of
circulatory overloading is well recognized, especially in
heart conditions associated with left ventricular failure,
mitral stenosis, or pulmonary heart failure. Any trans-
fusion to remedy the anaemia must be given slowly, and
the use of packed red blood cells is advisable. The use
of iron, perhaps given intramuscularly, may sometimes
make transfusion unnecessary ....

“In order to reduce the oxygen consumption of the
tissues, hypothermia may be used, but it carries a greater
liability to ventricular fibrillation with increasing age and
in the presence of heart disease .... On the other
hand, the avoidance of hyperthermia, or even permitting
a few degrees of cooling, is of considerable benefit ....

“The blood pressure is maintained by the cardiac out-
put and the total peripheral resistance. The total periph-
eral resistance depends on the state of constriction or
dilatation of the arterioles. If these are dilated the blood
pressure will fall .... There is not yet agreement as
to the circulatory effects of the generally accepted anaes-
thetic sequences .... While there are difficulties in
assessing the haemodynamics of anaesthetic agents in
experimental animals and in healthy men, there is, for
obvious reasons, very little precise information from pa-
tients with cardiac disease ....

“The risk of anaesthesia often depends as much upon
the experience and skill of the anaesthetist and the pre-
operative degree of cardiac efficiency as upon the type
of heart disease .... In general, the risks to which the
patient with cardiac disease is exposed depend on the
nature of the proposed operation and its possible com-
plications and on the general cardiovascular status of the
patient. The type of anaesthetic, provided it is com-
petently administered and conforms to basic principles,
together with the specific nature of the cardiac disability
is usually of lesser importance. Nothing overrides the
truth that techniques and disease processes which impair
the oxygen supply to the heart are always a threat to
life.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, pages 16-18. Copyright by John S. Lundy.

•

PEDIATRIC ANESTHESIA, by L. D. Bridenbauch,
Jr.: J. Am. A. Nurse Anesthetists 24:155-163, 1956.
“Anesthetists who have had limited experience in admin-
istering anesthesia to children are still proceeding on the
theory that children are ‘just small adults,’ and that if an
anesthetic agent is appropriate for an adult, it is also
appropriate for a child. However, certain anatomical and
physiological characteristics peculiar to the child must
be recognized and, accordingly, the amount of anesthetic
agent and the technique of administering it must be suit-
ably altered ....

“Variations between the respiratory system of the child
and that of the adult are of the utmost importance to the
anesthetist. These include — Resilience of the bony part

of the thoracic cage, .... Incomplete development of

the lung tissue, Increased respiratory rate .... |

and Small tidal volume ....

“Peculiarities of the child’s cardiovascular system, im-
portant to the anesthetist, include — Inherent automatici-
ty, . . . . Increased heart rate, .... (and) Low blood
pressure, .... Blood loss during surgery is tolerated
poorly by infants because they have a small blood volume :
( roughly 80 cc. per Kg. ) and are naturally hypotensive, i
“The central nervous system of the infant also presents
variations from that of the adult. Most of them are due I
to the immaturity of the nervous tissue and result in —
Decreased sensation, .... and Increased incidence of
convulsions, . . . .The heat regulating centers of the in- >1
fant are immature ....

“The anesthetist should check to see that the patient
to be anesthetized has an empty stomach. Aspiration of
vomitus is as serious a complication in the child as it is
in the adult .... During the course of anesthesia an
infant frequently develops an acute distention of the
stomach. The cause for this is unknown .... The
child’s kidney is much less capable of dealing adequately
witli excess amounts of saline than is the adult’s kidney.

“A plea is made for those administering children’s
anesthesia to use the drugs and techniques with which
they are most familiar and to use them cautiously. If
this is done, pediatric anesthesia will truly be ‘anesthesia
without tears’ — on the part of both child and parents.”

From John S. Lundy' and Florence A. McQuillen: Anesthesia I
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, pages 28-29. Copyright by John S. Lundy*.

•

CONTRIBUTION TO THE THERAPY OF MYOCAR-
DIAL DEPRESSION CAUSED BY THIOPENTONE
SODIUM (STUDIED BY HIGH FREQUENCY CAR-
DIOMYOGRAPHY), bv A. Fronek and Z. Pisa: J.
Anaesth. 28:366-372, 1956.

“A fall in blood pressure occasionally occurs during
intravenous anaesthesia with various barbiturate prepa-
rations .... In the studies to be reported, there have
been analysed more closely the factors causing lowering
of the blood pressure during intravenous anaesthesia with
sodium thiopentone and we have attempted to influence
this decrease in pressure therapeutically. The effect of
this therapeutic intervention on the depth and duration
of anaesthesia has also been investigated .... Experi-
ments were carried out in a total of 15 dogs ....

“A weakening of ventricular contraction during intra-
venous administration of thiopentone has been demon-
strated with high frequency cardiomyography. A direct
depressant action on myocardial muscle by this drug has
also been demonstrated following its intracoronary ad-
ministration. It has been found that falls in blood pres-
sure caused by thiopentone are immediately reversible
by the intravenous administration of 5 to 10 ml. of
10 per cent CaCL.

“The intravenous administration of CaCL affects nei-
ther the duration nor the depth of anaesthesia in rabbits.

It has been emphasized that these findings may be of
some importance by increasing the safety of intravenous
barbiturate anaesthesia: (1) in patients with latent or
manifest ischaemic myocardial diseases; (b) in patients
in shock; (c) in cases of accidental overdosage or when
more toxic preparations are used.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 67. Copyright by John S. Lundy-.

36

THE JOURNAL-LANCET

symptomatic relief ... plus!

*pl I 111

achrocidin is a well-balanced, comprehensive formula for
treating acute upper respiratory infections.

Debilitating symptoms of malaise, headache, pain, mucosal
and nasal discharge are rapidly relieved.

Early, potent therapy is offered against disabling complications
to which the patient may be highly vulnerable, particularly
during febrile respiratory epidemics or when questionable middle
ear, pulmonary, nephritic, or rheumatic signs are present.

achrocidin is convenient for you to prescribe — easy for the
patient to take. Average adult dose: two tablets, or teaspoonfuls
of syrup, three or four times daily.

tablets

ACHROMYCIN ® Tetracycline

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Each teaspoonful (5 cc.) contains:
ACHROMYCIN ® Tetracycline

equivalent to tetracycline HC1 125 mg.

Phenacetin 120 mg.

Salicylamide 150 mg.

Ascorbic Acid (C) 25 mg.

Pyrilamine Maleate 15 mg.

Methylparaben 4 mg.

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' Keg. U. S. Pet. Off.

23 A

The Diagnosis and Treatment of
Endocrine Disorders in Childhood
and Adolescence, by Lawson
Wilkins, M.D., ed. 2, 1957.

Springfield, Illinois: Charles C

Thomas. $17.50.

This is a thorough revision of the
first edition of Dr. Wilkins’ excel-
lent textbook. In addition, the text
and illustrations have been expand-
ed considerably. The author has
done an excellent job in bringing
this book up-to-date at a time when
progress in this field has been very
rapid. Although not intended to be
a thorough treatise of every endo-
crine disorder in children, it is
without doubt the best available
source from which to start complete
coverage of any facet of endocrinol-
ogy in childhood. The notable ex-
ception is that diabetes in children
is not included. Now included is
the latest information on the steroid
physiology and clinical aspects of
diagnosis and treatment of the ad-
renogenital syndrome. The author
and his co-workers have been lead-
ers in this field, and their very val-
uable experience is documented in
a clear-cut, easily read section. In
addition, a new section is devoted
to the newer knowledge regarding
the “goiterous cretins.” An entire
new chapter has been included to

REVIEWS

familiarize the practitioner with new
diagnostic laboratory hormone de-
terminations. The purpose of this
chapter appears to be to familiarize
the clinician with the intelligent use
of these tests rather than to serve as
a laboratory manual. Such a pur-
pose is quite well fulfilled.

Each chapter of this book is writ-
ten in essentially the same form as
the first edition, although most
chapters have not only been revised
and brought up-to-date but also en-
larged. Very little material is in-
cluded that is not essential to the
understanding of the conditions dis-
cussed. The style creates a logical
sequence of written presentation and
is accompanied by fine illustrations.
The number of illustrations also
have been increased and are repro-
duced in excellent quality. The use
of schematic diagrams as well as

pertinent summaries of the illus-
trated pictures gives one the im-
pression of having worked with the
patient himself.

This book cannot be recommend-
ed too highly to any physician who
deals with children, including those
in the sub-specialties. It is also
recommended to owners of the first
edition, because so much new ma-
terial essential to understanding the
rapid advances which have been
made has been added since this
book was first published.

Robert Ulstrom, M.D.

•

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Wolstenholme and Elaine C.
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This volume should be brought to
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interested in the mode of action of
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supported by Ciba Ltd., of Switzer-
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presenting chiefly physiologic as-
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pertinent bibliography followed by
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•

The Surgical Management of Pul-
monary Tuberculosis, edited bv
John D. Steele, 1957. Spring-
field, Illinois: Charles C Thomas,
213 pages. $9.50.

This monograph is the first of a
series concerned with various phases
of thoracic surgery and dedicated to
Dr. John Alexander. It is fitting that
this initial volume should be con-
cerned with a subject to which Dr.
Alexander contributed so greatly,
and most of the participants are his
former residents. It is a reasonably
short but complete presentation of
current concepts regarding the sur-
gical treatment of pulmonary tuber-
culosis. The initial chapters trace
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ters outline the indications for vari-
ous types of resections and give
morbidity and mortality figures.
Combined collapse and resection
therapy is discussed, as is plombage
and the treatment of pleural tuber-
culosis. An interesting chapter on
thoracoplasty indicates the general
trend away from such a procedure
as an isolated form of surgical ther-
apy, although its use as an adjunct
either before or after resection is
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cases are pointed out, and such pro-
cedures appear to have considerable
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Urology and Industry, by Leonard
Paul Wershub, 1956. Spring-
field, Illinois: Charles C Thomas,
151 pages, 3 parts. $5.00.

The purpose of this book, as stated
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The evolution of industrial medi-
cine and Workmen’s Compensation
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liability. In the third part, 100 in-
dustrial urologic cases and their le-
gal connotations are adequately pre-
sented. Three typographical errors
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be vesical; on page 86, prostatis
should be prostatic; and on page
94, diverticuli should be diverticula.

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cerned with a subject with which
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industrial physician and urologist.
The bibliography is adequate.

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SERVING THE MEDICAL PROFESSION OF MINNESOTA,
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

The Treatment of Diabetic Acidosis

EDMUND B. FLINK, M.D., and THOMAS K. OLWIN, M.D.
Minneapolis, Minnesota

A brief review of the pathogenesis of diabetic
ketosis will be made in order to outline a
rational basis for therapy. The reader is referred
to the most recent Medical Progress review of
diabetes mellitus by Beaser.1

Diagnosis requires a clear definition of diabetic
acidosis and coma and adherence to strict cri-
teria. A state of coma, that is, a profound state
of unconsciousness, may occur in a diabetic
patient, as in any other person, without being
related to diabetic acidosis. The other most im-
portant cause of a comatose state in diabetic
patients is hypoglycemia. Many tragedies have
resulted from confusing hypoglycemia with dia-
betic acidosis, since the former is one of the most
i serious medical emergencies and must be treated
immediately. Other causes include head trauma,
cerebrovascular occlusions, meningitis, encepha-
litis, and brain tumor. Any of these conditions
could also be the precipitating factor in acidosis.

Because of these considerations, a diagnosis
of diabetic acidosis should not be made and in-
tensive treatment should not be given unless the
following criteria are present: ketonemia and
hyperglycemia (and, usually, ketonuria and gly-
cosuria), decrease of carbon dioxide content or
capacity to less than 15 mEq./l., and clinical
evidence of acidosis and dehydration. Milder
ketosis than this needs prompt treatment with

edmund b. flink is chief of the Medical Service
at Veterans Administration Hospital, Minneapolis.
thomas k. olwin is with the Department of Medi-
\cine at Veterans Administration Hospital.

insulin and other measures but doesn’t require
the heroic treatment which will be discussed in
detail. Obviously, prevention of severe acidosis
by the early treatment of ketosis is better than
the best later management of severe acidosis.

PATHOLOGIC PHYSIOLOGY OF DIABETES ACIDOSIS

Lack of insulin is of prime importance and re-
sults in impaired glycogenesis, increased glvco-
genolysis, and failure of the glycolytic cycle. This
causes insufficient pyruvic acid production and
disturbance of metabolic equilibrium with keto-
nemia and ketonuria (acetone, aceto-acetic acid,
beta-hydroxybutyric acid). The ketonemia and
ketonuria, the hyperglycemia and glucosuria, in
turn, result in polyuria, cellular and extracellu-
lar dehydration, loss of electrolytes, and acidosis.
These processes develop as a chain reaction and
can be reversed only by adequate insulin and
replacement of fluids and electrolytes which
have been lost. The lack of insulin may be due
simply to failure to administer it, an increased
demand due to infection, stress, and so forth,
or to previously unrecognized diabetes. It is
important to ascertain immediately the precipi-
tating factor in each instance.

Three studies have defined clearly the very
large fluid and electrolyte deficits which occur
in diabetic acidosis.3-5 Two of these studies re-
cord the cumulative negative balances during
production of acidosis by insulin withdrawal,
and the third records balance studies of a group
of 5 patients during recovery from acidosis.
Table 1 summarizes the findings of these studies.

TABLE 1

Atchley

Butler

Nabarro

Body size

58 kg.

68 kg.

1.73 sq.m.

Water, liters

3.8

6.6

5.5

Sodium and

magnesium, mEq.

216.

Sodium, mEq.

322.

428.

Magnesium, mEq.

50.

40.

Potassium, mEq.

362.

388.

339.

Chloride, mEq.

42.

272.

390.

Phosphorus, gm.

4.6

5.

1.13

Severe enough acidosis developed on the
fourth day in the patient of Atchley and associ-
ates3 so that the experiment was stopped at a
time when the C02 was 14.6 mEq./l. The data
recorded in table 1 were actually observed. The
observations of Butler and associates4 are part-
ially derived data in that theoretic losses from
severe acidosis are added to those actually ob-
served and are included, since the acidosis was
not permitted to progress to a serious point. The
data of Nabarro and associates5 are the actual
cumulative balances from 5 patients being treat-
ed for diabetic acidosis. These latter data, there-
fore, are the most representative, but the close
similarity of all 3 studies is very impressive. It
is noteworthy that the extracellular losses repre-
sent from 20 to 25 per cent of the total extracellu-
lar volume and that the potassium loss repre-
sents 8 to 9 per cent of body stores.

If one uses 70 kg. as the weight of a 1.73
square meter person (Nabarro study), the aver-
age losses in Butler s and in Nabarro ’s studies
can be expressed as follows on a per kg. basis.

Butler

Nabarro

Water, ml. /kg.

100.

80.

Sodium, mEq. /kg.

5.

6.

Chloride, mEq. /kg.

4.

5.5

Potassium, mEq. /kg.

6.

5.

Magnesium, mEq. /kg.

0.8

0.6

Phosphorus, mg. /kg.

70.

15.

It is evident from Nabarro's detailed data that
there is quite a bit of variability in certain items,
particularly in nitrogen and phosphorus. It is
also clear that mild acidosis of short duration

is associated with much smaller cellular ion
losses but often nearly maximum extracellular
fluid losses. The importance of these studies can-
not be overestimated, for they permit us to make
a reasonable calculation of the requirements of a
patient with diabetic acidosis. The studies em-
phasize the fact that large quantities of both
intracellular and extracellular ions are lost.

The recognition of fatal respiratory paralysis
due to hypopotassemia during the course of
treatment of diabetic acidosis6 marked a mile-
stone in the understanding of potassium metabol-
ism. Many cases have been reported since then
of serious hypopotassemia. In spite of their con-
certed effort to prevent hypopotassemia, Smith
and Martin” found that the largest single cause of
death in their series was hypopotassemia, since
inadequate amounts of potassium were adminis-
tered in some cases. “Some” potassium is not
sufficient, hut at least 1/3 and preferably 1/2
of the theoretic deficit is necessary in the first
twelve to sixteen hours.

A brief case report bears out the need for
vigorous therapy. This patient, age 23, had class-
ical symptoms of diabetes mellitus for three
weeks and then acidosis developed. His treat-
ment for the first forty-eight hours at another
hospital and for the next forty-eight hours at this
hospital is outlined in table 2.

He was admitted to the Minneapolis Veterans
Hospital because of progressive weakness to the
point of severe generalized paresis. Some cloud-
ing of sensorium and typical electrocardiographic
changes of hypopotassemia were noted on ad-
mission. Unnecessarily large amounts of sodium
salts were administered during the second fortv-
eight-honr period. The ready-made solution used
in this instance had an inadequate concentration
of potassium for the treatment of a known potas-
sium deficit. Such solutions are adequate only
for daily maintenance unless an ampule of po-
tassium salt is added.

Nabarro and co-workers5 emphasize the fact
that bowel function and a feeling of well-being
were brought to normal more rapidly when ade-
quate potassium was supplied early in treatment.
The transfer of sodium into cells when potassium

TABLE 2

J.T.W., 23

Insulin

Water

Na.

Cl.

Lactate

K.

Mg.

HPOi

Rx. first 48 hours
Paralysis
Serum K. 1.9

1,200

7,000

481

460

75

75

18

37

Rx. second 48 hours
Strength good
Serum K. 3.2

6,000

579

745

50

230

12

25

38

THE JOURNAL-LANCET

was not used can be prevented to a large extent
by use of potassium. They emphasize the fact
that potassium (and probably also magnesium
and phosphate) are indicated for general meta-
bolic functions of cells and not simply for pre-
vention of an occasional instance of cardiac
arrhythmia or respiratory paralysis.

THERAPY

General measures. Diabetic acidosis must be re-
garded as a major medical emergency. A physi-
cian should be in attendance all the time. Local
infections of the skin, ears, respiratory or urin-
ary tract, and systemic infections should be look-
ed for and treated adequately with antibiotics.
A detailed history of the diabetes from an in-
formant, if necessary, should include information
about insulin dosage and sensitivity, other epi-
sodes of coma, precipitating episodes, and so
forth.

A chart of the important clinical and chemical
data is imperative. This chart should include:
pulse, blood pressure, state of consciousness,
urine volume, urine sugar, urine acetone and di-
acetic acid, blood glucose, carbon dioxide ca-
pacity, sodium, potassium, plasma acetone, blood
urea nitrogen; therapy: insulin, fluid volume,
sodium, potassium, chloride, lactate (or bicar-
bonate), phosphate, magnesium, glucose; and
space for comment on associated illnesses. It is
important to keep this chart current.

Each chart must be individualized, but a few
generalizations can be made. Some data, such
as vital signs, should be cheeked every half hour
and oftener if shock exists, of course. Urinalysis
should be recorded hourly. Plasma acetone and
blood glucose can profitably be checked every
two hours until recovery is well under way. The
carbon dioxide combining power could be check-
ed at six hours, but, if the course is favorable
clinically, it need not be determined again. In
order to detect hvpopotassemia, serum shoidd be
obtained six to twelve hours after starting insulin
for optimum results.

When the initial serum potassium is normal in
a patient with severe acidosis and, especially,
when the blood urea nitrogen is elevated, the

need for potassium is greater, and therapy must
be started earlier and given more vigorously.
Serial electrocardiograms from the start of ther-
apy are particularly valuable as an aid to potas-
sium administration, since the information is
immediately available. A single lead, such as V:!,
is all that is needed for these comparative pur-
poses and should be obtained every hour or two.

A severity index8 may be calculated from the
data charted to roughly determine the prognosis,
but it is more important to alert the physician to
the need for vigorous therapy because of un-
favorable signs. Such an index, furthermore, has
the real advantage of calling attention to the
most important unfavorable variables, some of
which are often ignored in routine management.
Zieve and Hill8 concluded their study as follows:
“considered individually, the order of effective-
ness of the significant prognostic variables was
age, blood pressure (i.e. hypotension), associated
conditions, blood urea nitrogen, degree of un-
consciousness, and duration of coma.” The need
for individualizing treatment according to sever-
ity of illness is strongly suggested by the statisti-
cal study of Zieve and Hill.9 They found no
significant differences in treatment in spite of
great differences in severity of illness. As shall
be apparent later, there appears to be a particu-
lar need for individualizing the dose of insulin.
The score can easily be calculated from table 3. 8

Zero is the dividing line between those who
have a poor prognosis (negative score) and those
who have a better prognosis (positive score).
The quantitative value of term I is obtained di-
rectly from table 4.

Insulin. The insulin dose used is the subject
of considerable controversy. Smith and Martin7
found that there was no significant difference in
response of patients given 80 units, 160 units, or
240 units initially and every two hours thereafter
until hyperglycemia decreased significantly. To
the contrary, however, others believe that an in-
crease in insulin dosage has been responsible for
great improvement in morbidity and mortal-
ity. 10-1 - The following doses were used in a large
group of patients who were treated at the Joslin
Clinic (table 5).

TABLE 3

SUMMARY OK INFORMATION NEEDED TO CALCULATE SEVERITY SCORE

Severity score = 1 + 11 — III

I = ( 14 AC + 7 DU) AC = associated condition

DU = degree of unconsciousness

II = (0.3 BP + 0. 1 BS) BP = mean blood pressure (S + D)/2

BS = blood sugar, mg./ 100 cc.

Ill = (DC + BUN + 44) DC = duration of coma/hr.

BL^N = blood urea nitrogen. mg./lOO cc.

FEBRUARY 1958

39

TABLE 4

RATING OF AC

0

i

2

3 4

5

§ 0

27.9

14.5

7.6

2.0 —4.6

—15.6

fc 1

21.4

8.1

1.1

—4.4 —11.0

—22.0

o 2

15.6

2.2

—4.7

—10.2 —16.9

—27.9

2 Q

H °

10.2

—3.2

—10.1

—15.6 —22,3

—33.3

2 4

4.2

—9.2

—16.1

—21.6 —28.3

—39,3

Rating scheme of AC

Rating scheme of DU

0 None

0 Conscious and alert

1 Very mild

1 Drowsy

2 Mild

2 Semiconscious

3 Moderately

severe

3 Unconscious but responds to pain

4 Severe

4 Unconscious and unresponsive

5 Very severe

TABLE 5

BLOOD SUGAR

LEVEL CORRELATED WITH INSULIN DOSE IN 153 COMA CASES

Blood sugar

Average insulin

Average insulin

on admission

in first 3 hours.

in first 24 hours.

mg. per 100 cc.

Cases

units

units

1,300-1,600

2

800

1,775

1,000-1,300

12

490

826

600-1,000

51

317

482

400-600

46

224

370

200-400

40

110

155

100-200°

2

56

123

•Low values due to administration of insulin on way to hospital

Duncan12 recommends the following initial
doses of insulin according to the severity of the
acidosis as measured by plasma acetone reaction:

Initial insulin dose

Plasma acetone test

100 units

4+ undiluted

200 units

4-f 1-2 diluted

300 units

4-f 1-4 diluted

400 units

4-f 1-8 diluted

Following the initial doses, as much as 100 units
is given every half hour until plasma acetone
is less than 4-f in undiluted plasma.

In a review of 25 instances of diabetic acidosis
studied at this hospital, the average doses used
were:

Initial
blood sugar

Average insulin dosage
Total

6 hours 24 hours

1

1,136

475

725

1

660

100

160

12

400-600

255

374

10

296-400

195

248

1

396

780

1,030

Total 25

296-1,136

262

355

The group of patients treated is too small to
draw many conclusions from the study. Review- I
ing the charts individually indicated inadequate
early insulin dosage in some. One patient singled
out for attention had a blood sugar of 396. He I
received invert sugar in large amounts almost
from the start of therapy with the result that
hyperglycemia was prolonged, and he received
what would otherwise have been an unnecessar- I
ily large dose of insulin.

The initial dose of insulin should be large and
can be given intravenously or half intravenously
and half subcutaneously. Unless there is a his- i
tory of marked insulin sensitivity, the initial dose
should be 100 units. If the blood glucose is over
700-mg. per cent, the initial dose should be 200
units, and if the blood glucose is over 1,000 mg./
per cent, it should be 300 units. Depending on
the severity of the acidosis, a dose of 50 to 100
units should be repeated every half hour for two
hours. The most important consideration is the
close observation of the glucose response to in-
sulin in the first four hours. Failure to respond
in this time calls for increase in insulin dose.

Fluid and electroh/tes. The following fluid re-
placement therapy for an average sized adult is

40

THE JOURNAL-LANCET

TABLE 6

Fluid

Electrolytes to be added

1. 1,000 cc. distilled water

2. 1,000 cc. distilled water

3. 1,000 cc. 5% glucose

4. 1,000 cc. 5% glucose

5. 1,000 cc. 5% glucose

Two 44 mEq. (3.75 gm.) ampules NaHCCL and one 50 mEq. (2.92 gm. ) vial NaCl.
One ampule NaIICO;, and two vials NaCl.

One ampule NaCl. and one 40 mEq. (2.98 gm.) ampule KCL.

One ampule NaCl., 40 mEq. ampule KJIPO,, and 2 gm. MgSO, (17 mEq. Mg.++).
One ampule K-HPO., one 20 mEq. ampule KCL, and 2 gm. MgSO,.

TABLE 7

Water

Na.

Cl.

HCOs

K.

HPOn

Mg.

Glucose

1.

1,000 cc.

139

50

89

2.

1,000 cc.

144

100

44

3.

1,000 cc.

50

90

40

50 gm.

4.

1,000 cc.

50

50

40

40

17

50 gm.

5.

1,000 cc.

20

60

40

17

50 gm.

Total mEq.

383

310

133

140

80

34

based on knowledge of average losses. Of course,
this therapy has to be individualized. Concen-
trated ion solutions can be added to a liter of
water to make up the solutions as shown in
table 6. These solutions will provide the elements
shown in table 7.

Appropriate adjustments of these amounts can
easily be made for smaller adults and for child-
ren. Children require relatively more water, and
this can be accomplished by giving somewhat
more dilute solutions. Usually, the patient is
able to begin oral feeding, including potassium,
after this amount of fluid has been given, hut
some patients require continued parenteral fluid.
Potassium chloride (40 mEq.) should be added
to the sixth liter, and potassium phosphate (40
mEq.) should be added to the seventh liter of 5
per cent glucose solution. If symptoms or signs
of hypopotassemia (weakness, respiratory par-
alysis, and electrocardiographic changes) super-
vene in spite of the aforementioned potassium
therapy, the concentration can be increased to
80 mEq./l.

It is possible to use commerciallv available

solutions to accomplish approximately the same,
results (table 8). One can substitute half-strength
lactated Ringer’s solution to which is added 40
mEq. of potassium phosphate to 1 liter and 40
mEq. of potassium chloride to the other. Butler’s
solution can also be used. Still other solutions
with this approximate composition can be sub-
stituted.

On admission, shock or borderline shock may
be corrected by the rapid infusion of the first 2
liters of fluid, since simple hypovolemia may be
the cause. However, not all patients with shock
will respond, and, particularly, those with pro-
found shock will require a plasma expander, such
as 6 per cent dextran solution or whole blood or
plasma. In some instances, noradrenalin (or
other vasopressor substances ) may be needed to
maintain blood pressure if plasma expanders in
reasonable amount fail to do so.

Potassium should be started about four hours
after starting insulin. In general, potassium
should not be administered unless urine flow is
adequate. However, if respiratory symptoms or
grave electrocardiographic abnormalities occur.

TABLE 8

Volume

Na.

Cl.

Lactate

K.

HPO,

Mg.

Ringer’s lactate

1,000

130

107

28

4

Ringer’s lactate

1,000

130

107

28

4

“Electrolyte No. 2

1,000

57

70

25

45

12.5

6

“Electrolyte No. 2

1,000

57

50

25

45

32.5

6

Glucose 5 % with KC1.

1,000

20

60

40.

5,000

374

354

106

158

85.

12

“Plus 20 mEq. potassium chloride to 1 liter and 20 mEq. potassium phosphate to the other.

FEBRUARY 1958

41

a small amount of potassium (40 mEq.) should
be given. Extremely careful observation is neces-
sary under these circumstances. Some initial
potassium deficit would be an advantage during
the treatment of prolonged anuria, but hvpopo-
tassemia could also aggravate the renal damage
or cause death from arrhythmia or paralysis.

In the presence of congestive heart failure or
alter acute myocardial infarction, the fluid pro-
gram has to be greatly modified. When edema
exists in heart failure, the extra fluid stores will
be called on, and the primary and, often, only
therapy is adequate insulin administration. Since
the electrocardiogram becomes useless to detect
hypopotassemia in many cardiac patients, po-
tassium determinations are needed to decide
whether to administer potassium.

A review of the course of treatment of 25
patients with diabetic acidosis treated at this
hospital from 1952 to 1955 was made to deter-
mine how the general principles mentioned
before were actually put into practice. Some
records showed many defects, whereas others
approached ideal management. There were no
deaths, but onlv 3 patients were actually coma-
tose and the severity in general was not as great
as in many reported series.

The following records the average fluid and
electrolyte therapy of 25 instances of diabetic
acidosis (in 17 patients) during the first twenty-
four hours.

REFERENCES

1. Beaser, S. B.: Diabetes mellitus (medical progress review).
New England J. Med. 255:173, and 223, 1956.

2. Field, J. B., Stetten, DeWitt, Jr.: Observations on causes
and mechanism of insulin resistance during diabetic acidosis.
J. Clin. Investigation. 35:703, 1956.

3. Atchley, D. W., and others: On diabetic acidosis; detailed
study of electrolyte balances following withdrawal and re-
establishment of insulin therapy. J. Clin. Investigation. 12:
297, 1933.

4. Butler, A. M., and others: Metabolic studies in diabetic
coma. Tr. Assoc. Am. Physicians. 60:102, 1947.

5. Nabarro, J. D. N., Spencer, A. G., and Stowers, J. M.:
Metabolic studies in severe diabetic ketosis. Quart. J. Med.
21:225, 1952.

6. Holler, J. W.: Potassium deficiency occurring during treat-
ment of diabetic acidosis. J.A.M.A. 131:1186, 1946.

Water, cc. 5,700

Sodium, niEtj. 525

Potassium, mEq. (20°) 105

Chloride, mEq. 454

Bicarbonate, mEq. (18®) 150

Phosphate, mEq. (7®) 77

“Number of instances where the ion was administered.

Since the figures shown are average, some
patients received inadequate amounts and some
excessive amounts. The extremes were 155 mEq.
of NaCl. in 1 patient to 1,065 mEq. of sodium,
783 mEq. of chloride, and 332 mEq. of bicarbo-
nate in another. Potassium therapy was inade-
quate in many instances. These figures do not
take into account electrolytes and fluid lost in
the urine. Rapid control of hyperglycemia and
ketonemia minimize such losses.

SUMMARY

An attempt has been made to present a form of
therapy for diabetic acidosis which is based on
knowledge of deficits which occur during the
development phase of acidosis. Major emphasis
has been placed on a correct diagnosis, large
doses of insulin given early, treatment of allied
and precipitating conditions, early and repeated
determinations of desired progress of glucose
and ketone levels, and a reasonable approach to
replacement of deficits of fluid and electrolytes
known to exist in diabetic acidosis.

7. Smith K., and Martin, H. E.: Response of diabetic coma to
various insulin dosages. Diabetes 3:287, 1954.

8. Zieve, L., and Hill, E.: Prognosis in moderate or severe
diabetic acidosis. Arch. Int. Med. 92:63, 1953.

9. Zieve, L., and Hill, E.: Comparative importance of severity,
and therapeutic effort in determining outcome of diabetic
acidosis as observed in a representative group of patients. J.
Lab. & Clin. Med. 43:107, 1954.

10. Harwood, R.: Diabetic acidosis. New England J. Med. 245:
1, 1951.

11. Joslin, E. P., Root, H. F.. White, P., and Marble, A.: The
Treatment of Diabetes Mellitus, ed. 9. Philadelphia: Lea &
Febiger, 1952, p. 371-373.

12. Duncan, G. G.: Diabetic coma — therapeutic problem. Ann.

Int. Med. 37:1188, 1952.

42

THE JOURNAL-LANCET

Trauma and Thrombophlebitis

JOHN FARR, M.D., F.R.C.S.(C.) (Edin.)
Winnipeg, Manitoba

Thrombophlebitis in the lower extremities
is sometimes a late complication of severe
injury elsewhere than in the legs. It may de-
velop days or weeks after such an injury. After
a fracture of the spine or the femur, patients are
usually at rest in bed and, in addition, have suf-
fered trauma to their soft tissues. The mechan-
ism of thrombosis in such patients is thus very
similar to that of thrombophlebitis occurring
after surgical procedures, and the later effects
of the thrombophlebitis are usually recognized
and treated because the acute phase has been
recognized.

There is another group of cases of great im-
portance, namely, direct injuries to the leg,
which may or may not result in fracture. Re-
cause the swelling may be thought to be due
to simple trauma or because the limb is hidden
in a cast, the resultant thrombophlebitis is fre-
quently not recognized. The high incidence of
this condition is evidently not appreciated and,
therefore, it is frequently not treated early or
with the vigorous postphlebitic management that
such a case should have. Reviewing the litera-
ture for the last ten years fails to reveal one
article on thrombophlebitis directly related to
trauma. The absence of literature on the subject
indicates either a lack of awareness or indiffer-
ence to this condition. Recause of the consid-
erable disability that results when the postphle-
bitic changes have progressed to a stage where
the patient is unable to work, despite his recov-
ery from the original Tin jury, careful evaluation
and recognition of this condition is important.
Dr. D. J. Fraser has kindly provided me with
some data on such patients taken from the Work-
men's Compensation Board’s files here. They are
not statistical samplings but illustrate how im-
portant the disability in certain cases may be.
A few illustrative examples follow.

A 28-year-old male had a fractured calcaneus and
ischium in 1952. He did not work for approximately
a year. In May 1956, four years later, lie was receiving
a 5 per cent disability for thrombophlebitis. There was
a 4-cm. difference in the circumference of the leg.

A 39-year-old male fractured his tibia and femur in

john farr is a lecturer in surgery at the University
of Manitoba and a surgeon at the Winnipeg Clinic.

1943. This patient suffered mostly from postphlebitic
edema, and permanent disability was 30 per cent. He
would have received 40 per cent if he had had an am-
putation.

A 50-year-old male, who suffered bruises and swelling
of both legs and thighs in December 1946, was dis-
charged from the hospital in February 1947 and returned
to work in April 1947. However, he had a continuing
disability, and, in 1949, a bilateral sympathectomy was
performed. In April 1956, he was receiving a 10 per
cent disability pension for the effects of old thrombo-
phlebitis.

A 48-year-old male, who suffered a fractured meta-
tarsal in July 1953 and had pronounced swelling after
removal of the cast, was admitted to the hospital for
anticoagulants. In 1956, his pension was reduced from
25 to 15 per cent.

A 54-year-old male, who fractured his left tibia and
fibula in 1953, is now receiving a permanent disability
of 25 per cent for bilateral phlebitis, 5 per cent of which
is related to a limited flexion of the knee.

A 32-year-old male twisted his right ankle while shov-
eling coal and returned to work in a month. He was
thought to have cellulitis and eventually had his veins
ligated. This patient works from time to time, but ulcers
recur.

Many of these patients with lower leg frac-
tures or contusions are disabled because of ven-
ous insufficiency long after the orthopedic or
traumatic surgeon has dismissed them as healed.
In some cases, it may be thought that the patient
is exaggerating his disability. Patients should
not be pampered, but any patient with a limb
that is swollen 2 to 4 cm. more than the other
leg should be treated as if he were suffering from
the effects of deep venous insufficiency, because
it is impossible to tell whether the edema and
cyanosis are due merely to loss of vascular tone
and increased permeability of the vessels or
whether the patient actually had a deep throm-
bophlebitis at the time of the original injury.
Whatever the cause of the edema, if appropriate
measures regarding management are not insti-
tuted, a serious disability will probably result.
These patients deserve treatment to reduce the
edema, because, if the edema is allowed to per-
sist, it eventually becomes irreversible. The plas-
ma outside the blood vessels tends to fibrose, and
this fibrosis leads to some degree of anoxia of
the skin, which, in turn, leads to further fibrosis
and scarring of the lymphatics. Ultimately, the
skin changes appear with the typical stigmata of
chronic deep venous insufficiency. I am not sug-

FEBRUARY 1958

43

gesting that patients with soft tissue injuries and
fractures of the lower leg should receive anti-
coagulants, because such treatment might cause
certain complications. However, I feel that when
plaster casts or other methods of immobilization
or support are removed from these patients, it
is of great importance to direct careful attention
toward the management of the edema of the
limb because, in some cases, deep thrombophle-
bitis will have occurred.

The surgical treatment of this form of throm-
bophlebitis includes various procedures, depend-
ing upon the stage of the thrombophlebitis and
the nature of its complications. These measures
include femoral or popliteal vein ligation, sym-
pathectomy, and excision with skin graft.

My experience leads me to believe that the
procedure of choice must be carefully selected
on an individual basis in order to secure the most
beneficial result.

Irrespective of this, however, by far the most
important management is that outlined in the
“New Way of Life,” described by Luke1 in 1950.
This important communication stresses the me-
chanical measures necessary to prevent develop-
ment of edema and avoid the consequent irre-
versible changes that will occur.

The patient is given typed instructions regard-
ing the importance of intermittent high eleva-
tion, constant elastic support on the limbs when
in a dependent position, and is warned of the
dangers of strong soaps and actinic (sunburn)
trauma. A genuine effort must be made to have
the patient understand his or her condition. The
only way dependent edema can be kept at a
minimum is by intermittent elevation of the legs
and properly applied elastic bandages or hose.
The importance of these measures must be em-
phasized and re-emphasized!

It is my feeling from a practical point of view
that it does not really matter whether the cause
of chronic venous insufficiency is an actual
thrombophlebitis or merely a temporary venous
insufficiency occasioned by prolonged immobil-
ity and lack of muscular action. The effect is the
same in both, although, of course, it is more
severe in the former than the latter. A delay in
returning to work and a recurring or permanent
disability may be avoided if considerable atten-
tion is paid to the care and management of pa-
tients with edematous extremities which develop
after injuries.

THROMBOPHLEBITIS IN UPPER EXTREMITIES

Venous thrombosis in the arm is of considerable
interest. I do not refer to thrombosis induced
by chemical irritation, such as occurs after in-

travenous injection of Diodrast or anesthetic
agents, or thrombosis induced by stasis in the
superior vena cava syndrome. However, I would
like to draw attention to a type of venous throm-
bosis described as “Ideopathic Thrombosis of the
Axillary Vein.” French authors have a more de-
scriptive term, “Thrombophlebite Axillaire Par
Effort,” which serves to distinguish it from
thrombosis or thrombophlebitis caused by direct
external injury. Rudolph Matas,2 renewing at-
tention to the condition in 1934, called it “Pri-
mary Thrombosis of the Axillary Vein Caused
by Strain." Such a term is, perhaps, clumsy but
does emphasize the most important factor in its
etiology. The condition is of more than passing
interest to a surgeon dealing with insurance or
workmen’s compensation cases.

Patients suffering from this type of thrombosis
do not usually give a history of injury or acci-
dent but, if interrogated, will recall an incident
of excessive muscular effort. The history of ex-
cessive muscular effort does not qualify a patient
for workmen’s compensation in Manitoba, as,
under the terms of the Compensation Act, a pa-
tient is required to be injured by “accident” be-
fore the Compensation Board will accept respon-
sibility for the injury. Accident may mean many
things to many people, but I think the definition
mentioned by Matas is a useful one, namely,
“an unforeseen event directly or indirectly atrib-
utable to the sudden, violent action of external
causes.” Some of the causes of this type of throm-
bosis mentioned in the literature are hoisting
heavy bales, heavy work with a hammer, lifting
objects onto a high shelf, vigorous rowing, crack-
ing a whip, and so forth. It is thought that the
mechanism of injury is as follows. During ex-
treme physical effort there is a coincidental ex-
treme respiratory effort which causes the axil-
lary vein to become distended so that it is more
likely to be injured. Then, for instance, at the
end of a rowing stroke, the clavicle is pulled
downwards and backwards, and the anterior sca-
lene muscle and the costocoraeoid ligament pro-
duce pressure on the vein with consequent trau-
ma, perhaps even causing a slight tear in the in-
tima. It should be mentioned that, despite a his-
tory of strain, axillary thrombosis is a complex
syndrome of polyvalent causation in which in-
direct trauma of the axillary vein and its imme-
diate environment play the leading role. To show
that there are other factors in the causation of
the thrombosis besides strain, I should mention
the case of one patient who required readmission
two davs after discharge from treatment for axil-
lary vein thrombosis. Her admission was neces-
sitated by a moderately severe iliofemoral throm-

44

THE JOURNAL-LANCET

bophlebitis. This, of course, suggested that some
increase in the clotting mechanism was present.

The condition is characterized by signs and
symptoms out of all proportion to the extent and
degree of the trauma. The arm swells and be-
comes livid or even cyanotic. The edema can
be firm or doughy. The veins over the chest wall
may or may not be distended. Usually, the pa-
tients are young and muscular and employed in
heavy labor. As might be expected, the sex in-
cidence in the male and female is 4:1.

In my own cases, the diagnosis of axillary vein
thrombosis has always been obvious and a veno-
gram did not seem to be necessary, especially in
view of the fact that injection of an opaque sub-
stance can itself cause venous thrombosis.

It should be mentioned that a roentgenogram
of the thoracic inlet and mediastinum is obliga-
tory to exclude lesions causing obstruction of
the subclavian or innominate veins.

Most patients respond very well to conserva-
tive measures: namely, elevation, heat, and anal-
gesics. The use of anticoagulants no doubt di-
minishes extension of the thrombosis, and, if

REFERENCES

1. Luke, J. C.: Evaluation of deep veins following previous

thrombophlebitis. Arch. Surg. 61:787, 1950.

facilities exist for their use, such therapy is ad-
visable. The majority of patients are relieved of
their symptoms in seven to fourteen days, and
the residua are minimal with none of the trouble-
some late complications occurring with venous
insufficiency in the lower extremity.

If symptoms persist, exploration of the appro-
priate supraclavicular fossa should be done. In
one such case requiring operation, I found an
elongated transverse process of C7 vertebra with
a fibrous band extending from its tip to the first
rib. Section of this resulted in cure.

No doubt some would advocate opening the
vein and removing the thrombus, but this pro-
cedure carries an unnecessary risk of air em-
bolism, recurring thrombosis, or embolism, and,
in my opinion, it should not be done.

Finally, it should be generally recognized, as
Matas stated, that there is a medicolegal differ-
ence between primary spontaneous thrombosis
caused by muscular strain (indirect injury) and
so-called spontaneous thrombosis, which occurs
without history of accident, antecedent injury,
or continued occupational strain.

2. Matas, R.: Primary thrombosis of axillary vein. Am. J.

Surg. 24:642, 1934.'

Exsanguinating hemorrhage from alimentary tract diverticula is most apt
to occur with extensive involvement of the colon. Although the exact mech-
anism of such hemorrhage remains obscure, infection is not incriminated.
Local trauma producing ulceration is the most important etiologic factor.

Because of the infrequency of the condition, treatment has not been stand-
ardized. When bleeding is slight, and often when massive, rest, sedation, bland
diet, and blood transfusions comprise satisfactory management. When bleeding
continues and the source is localized, an elective resection of the diseased bowel
is done. With massive bleeding from the entire colon, localization of the precise
bleeding point is usually impossible and the necessary total or subtotal colec-
tomy in this situation is a formidable procedure.

Simple diversion of the fecal stream controlled massive hemorrhage from
diverticulosis in 2 patients. Since bleeding from the right colon seldom occurs,
a transverse colostomy usually suffices. Definitive management can then be
settled on an individual basis.

Charles D. Knight, M.D., Confederate Memorial Medical Center, Shreveport, Louisiana. Sur-
gery 42:853-861, 1957.

FEBRUARY 1958

45

Pilonidal Disease

KARL ZIMMERMAN, M.D.
Pittsburgh, Pennsylvania

The following method of treating pilonidal
disease has been published twice before1,2
and has been explained to several medical groups
and societies. Because of the growing interest
and the number of requests received recently,
this simple method of treatment is presented
again with a series of more than 1,000 cases to
substantiate its efficiency.

Pilonidal disease is characterized by the pres-
ence of midline sinus tracts and associated cystic-
cavities usually found in the tissue over the
lower sacrum and coccyx. Similar sinuses and
cysts have been reported as occurring anterior
to the anus, on the upper back, in the navel, and
between the fingers of barbers. The condition
is more common in hirsute white males. About
half these cysts and sinuses contain hair. Sinuses
and dimples in the sacrococcygeal area are seen
frequently in children, but infected cysts are not.
The condition usually becomes symptomatic be-
tween the ages of 18 and 30. These are the same
years in which hydradenitis suppurativa is prev-
alent.

The cause of pilonidal disease is not yet
known. The sinus tracts may be congenital, but
there is no conclusive proof that they arise from
epithelial arrests, remnants of the notochord,
neurenteric canal, or preen glands as has been
suggested by various authors. There is much
reason to believe that the cysts, in contradistinc-
tion to the sinuses, are acquired and that they
are caused when hair and detritus from the skin
penetrate the sinus tracts and, along with bac-
teria, cause irritation and abscess formation.

Microscopically, pilonidal sinuses are found to
be lined with stratified squamous epithelium. A
cyst may be partially lined with stratified epi-
thelium, but most of the cavity is lined with in-
flammatory tissue. Occasionally, hair follicles are
found in a cyst cavity, but never are enough fol-
licles seen to explain the mats of hair sometimes
removed from pilonidal cysts. The hair in the

karl zimmerman is assistant professor of surgery
and head of the Section of Proctologi/ at the Univer-
sity of Pittsburgh School of Medicine.

Presented at the New Orleans Graduate Medical
Assembly , March 11, 1957.

cysts is not attached to follicles and is easily
lifted from the cavity. The amount and length
of the hair is often sufficiently abundant to refute
the theory that the hair in pilonidal cysts breaks
off the back and lodges in the sinuses.

The symptoms of pilonidal disease are the
same as those for localized subcutaneous infec-
tions anywhere in the body.

The number of operations described for the
cure of this condition is fantastic. During World
War II, a game was played in the Air Force in
which a surgeon “dreamed up” a method of
operating on pilonidal cysts. The literature was
then searched, and usually a description of the
“dream method” could be found. It was during
World War II that the Air Force, as part of the
routine physical examination for its members,
looked specifically for pilonidal disease. As a
consequence of this requirement, as many as
60 cases of pilonidal disease were present in
some station hospitals at one time. This wealth
of material provided an excellent opportunity
for the study of this disorder. It was in such
a hospital that the method of treatment pre-
sented here was developed.

After all reasonable methods of closure had
been tried and proved unsatisfactory because of
the recurrence rate, it was decided to try to
find a better open method than a wide block
dissection, which left a wound that required
months to heal.

The first patients operated upon after this de-
cision was made had their cysts and sinus tracts
unroofed. Sections were then taken from vari-
ous parts of the sinuses and evst cavities, and
drawings were made of the involved areas indi-
cating the location of removed sections. These
sections were examined microscopicallv, and the
findings were considered in regard to the loca-
tion from which they had been removed. It was
concluded that the walls of pilonidal sinuses are
covered by stratified squamous epithelium. This
stratified squamous epithelium extends for vary-
ing distances into the cyst cavities but never
completely lines them. Whether a cyst was ever
completely lined with stratified epithelium,
which was then partially destroyed by infec-
tion, was considered but rejected as unsubstan-

46

THE JOURNAL-LANCET

Fig. 1«. Preoperative picture of 2 congenital openings of pilonidal sinuses in the midline and an acquired opening
above and to the left. (bK Probe in congenital sinus, (c). Tract slit open showing hair in sinus and cyst cavity.
(d). Lining of sinus and cyst after being wiped free of hair and detritus. (eh Cotton saturated with 1:5,000 epi-
nephrine solution in wound. (f>. First postoperative day. (g). Eighth postoperative day. (hh Thirteenth postopera-
tive day. (V. Twenty-second postoperative day.

FEBRUARY 1058

47

tiated. It was more reasonable to assume that
the pilonidal cyst was an abscess cavity caused
by infection entering the lower end of a sinus
tract and extending through its sweat glands or
hair follicles into the surrounding tissue.

Whatever might have been the underlying
cause of pilonidal cysts, they healed rapidly and
with practically no recurrence when nothing was
done but a simple unroofing and cleaning pro-
cedure. Also, healing was much more rapid than
when a wide block dissection was made. In
view of the success of this procedure, more and
more of the roof of the cyst was allowed to
remain in place until the present procedure
evolved.

The method now used is simple. A probe is
passed into the sinus tract or tracts and cavities,
and the overlying tissue is separated with the
scalpel or scissors. The lining so exposed is
wiped clean with a piece of dry gauze. This lin-
ing is then examined and probed for side tracts
or cavities. If found, they are slit open the same
as the primary one. Palpating the tissue adjacent
to the tracts may reveal induration, which indi-
cates the presence of a side tract or cavity. This
procedure helps the operator find all the in-
volved areas. No tissue is removed unless the
cavity or tract is deep and there is chance of
the skin healing over before the wound is filled
with granulations. The edges of these wounds
are beveled in order to “saucerize” them and
prevent bridging. No ties are used on bleeders
if they can be avoided. The less foreign material
in the wound, the better it will heal. Bleeders
are pinched with hemostats and twisted. A piece
of gauze saturated with 1:5,000 epinephrine
solution or on a piece of Gelfoam or Oxycel is
placed in the wound, and a pressure dressing is

applied. Occasionally, a persistent bleeder is
found that requires control by electrical coagu-
lation or even a tie, but this is avoided if pos-
sible.

Six to eight hours after operation, wet dress-
ings of saline or boric acid solution are placed
over the pressure dressing which was applied at
operation. The next day, the pressure dressing
is removed, but the wet dressings are continued.
If bleeding has ceased, the patient is discharged
from the hospital on the second postoperative
day. The wet dressings are continued at home.

Twice each week following discharge from the
hospital, the wound is examined and dressed in
the office. At each visit, the entire healing area
is observed for signs of delayed healing or open-
ings to tracts that have been missed. If a tract
is found, it is unroofed under local procaine
anesthesia. Areas in which granulations are not
healthy are examined for the presence of a hair
or other foreign material, which is removed if
found.

It usually takes about ten days for all the
granulations to become clean and healthy. The
wet dressings are stopped at this time, and the
patient is advised to place gauze covered with
Furacin on the wound and to change the dress-
ings three or four times a day. A sanitary belt
and perineal pad are used to hold the wet dress-
ings in place and also may be used to retain the
Furacin dressings. Wet dressings are far more
beneficial than any ointment or cream-based
applications for the first ten days. After the
wounds are clean, creams in water-miscible bases
are most effective. Ointments with a petrolatum
base delay healing even though they do contain
antibiotics or antiseptics.

The known recurrence rate in these cases is

c

Fig. 2. Exten-
sive scar fifty
days postopera-
tively. Epitheli-
zation had been
complete nine
days.

Fig. 3. Scar of
pilonidal wound
seven years aft-
er operation.

48

THE JOURNAL-LANCET

less than 2 per cent, and recurrences are treated
in the same manner as the original infection.

Since this method is contrary to the accepted
teaching of the past, which states that all the
lining of a pilonidal cyst or sinus must be re-
moved in order to effect a cure, photographs of
the operation and the healing wounds were
taken as evidence of its validity. Some of these
photographs are presented to show that the
lining of a pilonidal cyst or sinus need not be
removed in order to cure the condition (figure
lrt through i ). Two pictures (figures 2 and 3)
of completely healed extensive scars are pre-
sented to show that large as well as small
pilonidal cysts may be cured by this method.
Figure 2 shows a scar seven weeks postopera-
tively, and figure 3 shows another scar seven
years after the operation.

The average time required for complete epi-
thelization in all cases is twenty-three days. Al-

REFERENCES

1. Zimmerman, K.: Pilonidal disease — an open method of

operation. Tr. Am. Proc. Soc. p. 515, 1946.

though it has been impossible to obtain definite
detailed statistics on all the cases that have been
treated by this method during and since World
War II, the number is well over 1,000 and the
known recurrence rate is less than 2 per cent.

This method can be used in the office for small
cysts and sinuses, but caution is urged because
the extent of the procedure is not always known
until the tract has been opened. The surgeon
may find that a more extensive operation is re-
quired than he wishes to perform in the office.

SUMMARY

A well-tested and simple method of successfully
treating pilonidal disease is again presented with
additional cases fortifying the gratifying results
previously reported.

Since this method is contrary to long-accepted
beliefs and teaching, photographs are shown to
verify the facts presented.

2. Zimmerman, K.: Surgical treatment of pilonidal disease.

J. Internat. Coll. Surgeons 24:104, 1955.

Needle biopsy of the kidney is a valuable procedure in the detection of or-
ganic renal disease, but it should not be performed unless the information to
be gained is of definite worth. Renal biopsy may be used to differentiate mul-
tiple renal diseases in the nephrotic syndrome and to aid in the diagnosis of
acute renal insufficiency and diffuse renal and vascular diseases. Often, the
stage of the disease process is revealed, and subsequent specific therapy im-
proves the prognosis.

Contraindications to renal biopsy include bleeding abnormalities; fulminat-
ing uremia; unilateral kidney; total anuria, unless a catheter is inserted and the
pelvis is irrigated; renal abscess or tuberculosis; perinephritis; and malignant
hypertension.

Biopsy, using local anesthesia and a Vim-Silverman needle, is performed
with the patient in the prone position. Attempts to obtain a successful biopsy
should be limited to 3.

Satisfactory renal tissue was obtained at first attempt in 137, or 91 per
cent, of 150 patients. Subsequent biopsies were satisfactory in 10 of the re-
maining 13 subjects. Glomeruli averaged 16 per section.

George E. Schreiner, M.D., and Leonard B. Berman, M.D., Georgetown University Hospital,
Washington, D.C. South. M. J. 50:733-739, 1957.

FEBRUARY 1958

49

The Clinical Significance of Hoarseness
and Related Voice Disorders

HANS VON LEDEN, M.D.
Chicago, Illinois

What is the chief function of the human
larynx? It is the production of voice, all
of us would agree, even though we remember
the importance of this organ as guardian of the
lower respiratory passages. This instinctive asso-
ciation between the human larynx and voice is
not surprising, considering the unique position
of voice and speech as the principal mediums of
communication among men. It is attested by the
translation of the Greek word “larynx” into the
English vernacular “voice box.” While the larynx
plays a prominent role in many other functions,
such as respiration, expectoration, deglutition,
and fixation, these functions are duplicated in
most vertebrates; but only man can “voice” his
thoughts.

This distinctive human property, which ex-
cludes the use of laboratory animals for inves-
tigations, has retarded our understanding of the
many complex phenomena which add up to the
production of voice. Recent experiments, includ-
ing the adaptation of ultra high speed cinema-
tography, have produced a better understanding
of the numerous physiologic derangements re-
sulting in hoarseness and related voice disorders.

A few fundamental principles of laryngeal
physiology will assist in a better understanding
of these phenomena. In normal voice produc-
tion, the lungs act as bellows which force air
under pressure against the lower surfaces of the
closed vocal cords, pushing them apart. Some of
the air escapes through this opening until the vo-
cal cords reapproximate— the result of their own
elasticity and the reduced lateral pressure in the
larynx. As soon as the subglottic pressure rises
sufficiently to overcome the resistance of the
vocal cords, the same cycle is repeated again
and again. These alternations create puffs of
air, which are perceived by the listener as

hans von eeden is assistant professor of otolaryn-
gology at Northwestern University Medical School,
medical director of William and Harriet Gould Foun-
dation, and attending staff physician at Chicago
Wesley Memorial Hospital, St. Fra
(Evanston), and Cook County Hog

sound or, modified by the organs of the upper
respiratory tract, as speech. Tlie shorter the in-
tervals between successive cycles, the greater
the frequency of vibrations and the higher the
pitch of the sound produced.

The process of voice production, therefore, in-
volves (1) the larynx as the primary source of
tone, ( 2 ) the chest as the source of the motive
power, (3) the resonance chambers of the head
and the pharynx, and (4) the related muscles
and motor nerves. Any variation may and often
does result in a change of sound, particularly if
the disturbance affects some of the vital muscles
in the larynx itself or their nerve supply. The
great number and diversity of the intrinsic laryn-
geal muscles attest to the complexity and deli-
cacy of the adjustments necessary for normal
voice production, and the length of the recur-
rent laryngeal nerve renders this main motor
nerve of the larynx particularly vulnerable.

Any modification of normal laryngeal function
results in one of three characteristic changes in
sound: A change in pitch, volume, or quality.
A change in pitch depends upon the mass and
tension of the vocal cords, not on their length,
as erroneously assumed for many years. The
volume varies with the pressure of the released
pulsations, that is, relative changes in the vibra-
tory cycle. Incomplete interruption of the air
flow, the creation of turbulences, or a change in
the vibratory pattern alter the quality of the
voice and give rise to hoarseness. Loosely speak-
ing, any change in the natural voice of an indi-
vidual is often referred to as “hoarseness."

From this brief description, it is quite appar-
ent that hoarseness is not a disease in itself but
rather a symptom of disease in the larvnx or
along the course of the laryngeal motor nerve.
Thus, hoarseness is the cardinal symptom of
laryngeal involvement. It may result from faultv
approximation of the cords, inadequate firmness
of the cordal margins, or even slight changes in
the vibratory pattern. It is often the first and
only sig'fial of serious local or systemic disease.
Several months ago, a patient consulted me
a historv of progressive hoarseness. As she

50

THE JOURNAL-LANC1

walked into the office, a slight limp was ob-
served. When she was asked to grasp her tongue
during the course of the examination, a wasting
of the thenar eminence became evident. Indirect
laryngoscopy showed a uniform weakness of
both cords, as seen in cases of muscular atrophy.
Somewhat rashly, I diagnosed amyotrophic lat-
eral sclerosis and referred the patient to a neu-
rologist who confirmed this diagnosis. On an-
other recent occasion, I was asked to see a pa-
tient with hoarseness of recent onset. Indirect
laryngoscopy revealed a weakness of one vocal
cord, but a neurologic examination proved en-
tirely negative. One week later, the unilateral
paralysis was complete, and I was able to pal-
pate a small, hard tumor at the thoracic inlet,
largely obscured by the clavicle. Roentgeno-
grams revealed an earlv malignancy of the ali-
mentary tract. These two patients are representa-
tive of the many unusual cases in individuals
who seek medical attention primarily because
they or their associates have noted the symp-
tom of hoarseness. Occasionally, the differen-
tial diagnosis may tax the ingenuity of the at-
tending physician, since hoarseness may be a
significant complaint in over 100 different med-
ical and surgical conditions.

The most common benign cause of hoarseness,
laryngitis, has been experienced by almost every
| adult at some time, and this familiarity “breeds
contempt.” As a result, many cases of laryngeal
disease remain undiagnosed for weeks or months,
while the opportunity for their successful eradi-
cation diminishes from day to day. Laryngeal
\ cancer is not uncommon and, in its early stages,
affords an excellent prognosis. Under these cir-
cumstances, who would quarrel with the old
dictum that all patients with a hoarseness of
more than three weeks’ duration deserve the
benefit of a laryngeal examination?

Such an examination must not be limited to
a cursory view into the mouth or, perhaps, a
brief glance into the throat. An adequate ex-
i animation for hoarseness includes careful inspec-
tion of the nose, paranasal sinuses, the mouth,
the nasopharynx and throat; a detailed study
of the hypopharynx and larynx; palpation of the
tongue, floor of the mouth, and the entire neck;
and such additional examinations and laboratory
studies as each individual case may warrant. If
indirect laryngoscopy with local anesthesia does
not permit complete visualization of the larynx,
a direct larvngoscopic examination under top-
ical,' intravenous, or inhalation anesthesia is in-
dicated. All suspicious lesions should be removed
for biopsy, for every doubtful case must be con-
sidered malignant until proved otherwise.

In the past, many physicians and patients have
been distressed by the difficulty experienced in
evaluating certain mild cases of hoarseness or
very early laryngeal lesions. The clinician has
been handicapped by the inherent limitations
of the human eye in distinguishing the rapid
motions of the vocal cords, which vibrate at a
rate of 200 to 400 cycles a second. Furthermore,
in direct larvngoscopic examinations, the distor-
tion of the normal anatomy by the introduction
of the rigid instrument is often sufficient to ob-
scure early changes in laryngeal function. Re-
cent comparative cinematographic studies by
Professor Paul Moore and the author, in normal
and ultra slow motion, during which laryngeal
vibrations are magnified 250 times, have demon-
strated the value of such studies in the diagnosis
of early functional abnormalities. With the per-
fection of the electronic synchron-stroboscope by
Timcke and by Van den Rerg, even minimal
lesions of the vocal cords can be discovered and
accurately interp reted. These recent additions
to our diagnostic armamentarium should encour-
age the successful investigation and treatment
of many baffling cases.

While hoarseness may be caused by an almost
infinite variety of organic or functional disor-
ders. this discussion will be limited to the more
common clinical entities.

INTRINSIC LESIONS OF THE LARYNGEAL
TISSUES

Inflammations. Inflammatory lesions comprise
by far the major portion of all laryngeal disor-
ders. Acute laryngitis, usually the result of an
upper respiratory infection or excessive vocal
use. is a self-limiting disease which responds
readily to supportive measures, minimal use of
the voice, and the avoidance of such irritants
as smoke, alcohol, and hot food. The same ap-
plies to the specific laryngitis accompanying con-
tagious or infectious diseases. Fortunately, with
the advent of antibiotic therapy, diphtherial lar-
yngitis, the dread scourge of past generations,
has practically disappeared. I have seen only
one case of this tvpe at the Cook Countv Hos-
pital during the past ten years. Early tracheoto-
my or intubation remains the treatment of choice
in these isolated cases. The same advice holds
true in children with acute laryngotraeheobron-
ehitis, where hoarseness acts as a warning signal
of beginning laryngeal edema.

Chronic laryngitis may be caused by an infec-
tion of the upper respiratory tract, particularly
a chronic sinusitis, or by a variety of irritants,
such as vocal abuse, excessive smoking, or in-
halation of dust or fumes. While the pathology

FEBRUARY 1958

51

may vary, a reversal ot the chronic changes may
best be accomplished by elimination of the etio-
logic factor, vocal temperance, and the absten-
tion from local irritants. Gargles and troches
have only psychologic value and may lure the
patient into a false sense of security. For em-
phasis, it must be repeated that a diagnosis of
chronic laryngitis should never be established
until a thorough examination of the larynx has
ruled out serious disease.

Laryngeal neoplasms. Laryngeal tumors fol-
low inflammations in their incidence but far sur-
pass them in importance. Benign tumors include
polyps, fibromata, and cysts, which may readily
be removed through the laryngoscope, and the
juvenile papillomata, which often recur after ex-
cision. Vocal nodules or “singers’ nodes” are
small tumors commonly seen in entertainers or
professional people. Frequently bilateral and
located at the junction of the anterior and middle
thirds of the vocal cords, they are the result of
persistent vocal overuse. In their early stages,
they are edematous and respond well to voice
rest and voice therapy. When fibrosis has taken
place, surgical removal becomes necessary.

Malignant tumors of the larynx are relatively
common, comprising over 2 per cent of all malig-
nancies. They strike principally in the fifth or
sixth decades of life, and 10 times as often in
men as in women. It cannot be stressed too
strongly that hoarseness is usually the only mani-
festation of early laryngeal carcinoma. Pain,
bleeding, dysphagia, dyspnea, stridor, and other
symptoms do not occur until late in the disease.
If confined to the vocal cords, carcinoma of the
larynx shows an excellent prognosis. In small
lesions, a cure may be predicted in 95 to 98 per
cent, while the cure rate is still about 80 per cent
when an entire cord is involved. The voice can
be expected to be good in these patients follow-
ing surgery. In expert hands, radiation may also
produce verv good results in early intrinsic laryn-
geal malignancies.

If the tumor has spread beyond the cords,
however, the prognosis is less favorable, and re-
moval of the lesion usually requires a laryngec-
tomy, with or without radical neck dissection,
by removing the organ of voice production, the
patient is doomed to a permanent tracheostomy.
In such cases, a new system of speech can usu-
ally be developed by utilizing the sphincteric
muscles at the upper end of the esophagus. This
striking contrast in the mortality and functional
end results of incipient or advanced laryngeal
carcinoma emphasizes more than many words
the vital necessity for early diagnosis of all sus-
picious lesions of the larynx.

Allergies. Angioneurotic edema or other aller-
gic conditions may involve the larynx and give
rise to hoarseness and rapidly progressive ob-
struction. An emergency tracheotomy should be
considered in acute cases to provide an airway
until medical treatment can reverse the larvn-
gea] manifestations.

Injuries. Traumatic lesions of the larynx may
occur as the result of external injuries with frac-
ture of the larynx, vocal abuse with cord hemor-
rhage, and gunshot wounds. Perhaps the most
common cause of hoarseness in this category is
the so-called “contact ulcer,” resulting from trau-
matic vocal abuse. In this condition, a super-
ficial ulceration develops on the medial surface
of the vocal process of the arytenoid cartilage,
which is exposed to constant hammering from
its mate during the vibratory cycle. Since these
ulcers are apt to recur, such patients deserve a
thorough analysis of their vocal habits, followed
by voice rest and indicated voice therapy. Slow
motion cinematographic or stroboscopic studies
often provide important information in these
cases, while, in my opinion, surgical intervention
is strictly contraindicated.

Persistent overexertion of the voice may also
result in weakness of the laryngeal muscles, with
associated hoarseness. This so-called myasthenia
laryngis is characterized by faulty or inadequate
approximation of the vocal cords on prolonged
stimulation. It is not related to myasthenia gravis
or any other systemic disease. Vocal temperance
and voice therapy are effective countermeasures.

DISTURBANCES IN INNERVATION OF LARYNGEAL
MUSCLES

Disturbances in the innervation of the laryngeal
muscles may be of central or peripheral origin.
In all cases, the treatment is that of the under-
lying disease, although voice therapy during con-
valescence may be helpful in improving the
functional end result.

Disturbances of central origin. Central lesions
include bulbar paralysis, which may be associ-
ated with numerous diseases of the central nerv-
ous system, multiple sclerosis, and tetanus. In
these diseases, laryngeal involvement is com-
monly bilateral, consisting of weakness or pa-
ralysis of both vocal cords, with varying degrees
of hoarseness and dyspnea. Tracheotomy is often
necessary to maintain an adequate airway and
to relieve the secretory obstruction of the lower
respiratory passages.

Disturbances of peripheral origin. Impulses to
the laryngeal muscles are carried by the vagus
and recurrent laryngeal nerves — a long and ex-
posed route. Thus, peripheral involvement of

52

TIIE JOURNAL-LANCET

the laryngeal nerve supply may stem from such
widely different sources as pressure by a tumor
in the neck or mediastinum, cardiac hypertrophy,
an enlarged thyroid, or an aortic aneurysm. In-
jury of the recurrent laryngeal nerve, on the
other hand, is usually the result of extensive
thyroid surgery. While the degree of laryngeal
paralysis varies from case to case, it is always
unilateral except in rare instances of bilateral
recurrent nerve injury during thyroid surgery.
In patients with persistent unilateral vocal cord
paralysis, the resulting hoarseness usually im-
proves over a period of time as the uninvolved
cord assumes the extra burden. Thus, complete
functional compensation may take place as the
result of effective adjustment to the altered
physiologic status.

Peripheral neuritis of the recurrent laryngeal
nerve may occur as a complication of influenza
or other virus diseases or in alcohol poisoning.
In these cases, the resulting paralysis and hoarse-
ness may be permanent, but it is often tempo-
rary, with normal function completely restored.

LARYNGEAL MANIFESTATIONS OF SYSTEMIC
DISEASE

Laryngeal manifestations of systemic disease are
far more frequent than is generally assumed.
Mild forms of hoarseness are often the result of
endocrine disorders, particularly during altered
thyroid metabolism. Muscular dystrophies may
affect the intrinsic muscles of the larynx, with
a resultant weakness in activity and functional
results. In many of these cases, slow motion
studies by svnchron-stroboscopy or ultra high-
speed photography are necessary to detect the
slight functional changes.

Tuberculosis of the larynx is rarely, if ever,
primary. With the decrease in active pulmonary
lesions, laryngeal tuberculosis is seen less and
less frequently. Hoarseness is commonly associ-
ated with pain in laryngeal tuberculosis, but for-
tunately streptomycin provides a specific rem-

edy. In this country, syphilis of the larynx has
become extremely rare.

VOCAL CHANGES WITHOUT DEMONSTRABLE
PATHOLOGY

Emotional disturbances or psychic trauma are
frequently responsible for psychosomatic hoarse-
ness or even aphonia. As opposed to organic dis-
orders, such patients often produce clear sounds
when encouraged to sing or hum individual
vowels or when their attention is channeled in
other directions. Psychosomatic aphonias may
be readily differentiated from organic paralyses
by observing the normal approximation of the
vocal cords while the patient coughs or clears
his throat. The peculiar history of these cases and
the associated psychologic manifestations usually
lead to the correct diagnosis, but the treatment
may prove unexpectedly difficult and often re-
quires prolonged psychiatric supervision.

SUMMARY

This discussion of hoarseness and related voice
disorders points to the following conclusions
concerning their clinical significance:

1. Hoarseness is the cardinal symptom of la-
ryngeal disease.

2. Hoarseness of more than three weeks’ du-
ration must be considered serious unless proved
otherwise.

3. Patients with persistent hoarseness deserve
a thorough laryngeal examination.

4. While hoarseness occurs in many different
systemic diseases, carcinoma of the larynx may
also occur in the presence of other diseases.

5. Earlv diagnosis and treatment of intrinsic
laryngeal malignancies produce excellent cura-
tive and functional results.

6. Newer additions to the diagnostic arma-
mentarium of the laryngologist permit a better
evaluation of early laryngeal lesions.

7. In benign lesions of the larynx, voice ther-
apy is often a useful adjuvant to indicated med-
ical or surgical treatment.

FEBRUARY 1958

53

Ovarian Tumors

CLYDE L. RANDALL, M.D.
Buffalo, New York

A DISCUSSION of ovarian tumors requires con-
sideration of a variety of important and in-
teresting neoplasms. We will not attempt to
review figures indicating the incidence of these
varied tumors or consider the ages at which
each is most likely to be discovered. There
seems little reason to describe findings which
might suggest that a cystoma is of one type or
another. We will try, however, to review some
of the points concerning ovarian tumors which
may be of interest and of some practical value
to the physician in general practice.

There should be little need to emphasize the
importance of first determining, especially when
the patient is young, whether the tumor is a non-
neoplastic dysfunctionally cystic enlargement or
a true neoplasm. Particularly, when the tumor
is no larger than the proverbial lemon, re-exam-
ination after a few weeks usually provides a sat-
isfactory means of differentiating cystic ovaries
and true cystomas. In younger women, when
ovarian enlargement has been observed to per-
sist through several menstrual cycles, the pres-
ence of a true neoplasm becomes evident and
laparotomy is indicated. If the patient is over
40, however, it is well to remember that dys-
functional cysts are less likely. Palpation of the
ovaries is particularly important after the meno-
pause, when, unfortunately, postmenopausal
changes make the ovaries difficult to outline.
In older women, any enlargement should be
regarded with apprehension, and laparotomy is
indicated if the impression of appreciable ova-
rian enlargement seems
tion under anesthesia.

Irregular bleeding is more apt to occur when
ovarian enlargement is due to dysfunctional cys-
tic changes and less likely with truly neoplastic
enlargement of the ovary. Nonfunctioning tu-
mors of the ovary are not apt to be associated
with abnormal uterine bleeding.

clyde l. randall is professor of obstetrics and
gynecology at the University of Buffalo School of
Medicine.

Paper presented at the third annual seminar,
Huron Road Hospital, Cleveland, Ohio, February
26, 1957.

confirmed by examina-

It is interesting that tumors have been report-
ed to develop more frequently in the left ovary
than in the right — in a ratio approximating 4
on the right to 3 on the left side.

It would be well to remember that chocolate
cysts due to ovarian endometriosis may be pres-
ent, though the patient does not complain of
the acquired type of dysmenorrhea so frequently
associated in our minds with endometriosis.
When chocolate cysts of the ovary are encoun-
tered and dysmenorrhea has been a complaint,
it is equally important to remember that ovarian
resection alone will probably not relieve the pa-
tient’s dysmenorrhea. Such menstrual pain is
usually due to adenomyosis, and a presacral
nerve resection or hysterectomy is usually nec-
essary when dysmenorrhea is a major complaint.

While chocolate cysts are the most frequent
neoplastic cause of ovarian enlargement, the der-
moid or the benign teratoma, as it is now so
frequently called, is the type of true cystoma
most frequently encountered. Teratomas are not
all dermoids, and all are not benign. Too often,
a solid teratoma is regarded as likely to be ma-
lignant, and a cystic tumor is considered prob-
ably benign. Actually, a solid teratoma may
prove to be benign, and the possibility of squa-
mous-cell carcinoma in a dermoid should not be
forgotten. Over 100 such cases have been re-
ported and, though the incidence is difficult to
determine, it must be something approximating
1 per cent. The frequency with which dermoids
involve both ovaries has been the subject of
considerable discussion. The larger series of
reported cases suggest the probability that bi-
lateral occurrence is less than 15 per cent.

The eystadenomas are probably the next most
frequent group of ovarian neoplasms. Here, a
careful appraisal becomes increasingly impor-
tant. So-called simple cystomas are usually uni-
locular and often pseudomucinous. As soon as
an ovarian cvst has been removed from the ab-
domen, it should be opened in order to deter-
mine if the lining is smooth or grossly papillary.
Removal without rupture of the cyst helps pre-
serve surgical ego and is generally considered
desirable. This practice involves removal of the
entire ovary, however, and disregards the possi-

54

THE JOURNAL-LANCET

bility of resecting a benign cystoma from unin-
volved perfectly normal portions of the ovary.
When the woman is under 50 years of age and
the tumor appears to he unilateral, the chance
of malignancy is slight. Under such circum-
stances, spill of the cyst content into the peri-
toneal cavity as a residt of attempting to pre-
serve a portion of the ovary is hardly to be re-
garded as a technical tragedy. We have repeat-
edly noted that pseudomyxoma peritonaei de-
velops only when a tendency to penetrate the
capsule and implant spontaneously onto adja-
cent peritoneum was evident the first time the
abdomen was opened. We have to date observed
no instance in which the spill of the contents
of a pseudomucinous cystoma resulted in the
peritoneal seeding of an implanting tumor if that
tendency was not evident when the abdomen
was first opened. Whenever the tumor is uni-
lateral, the opposite, apparently uninvolved look-
ing ovary should be bisected in order to make
certain that it shows no evidence of beginning
neoplasm before we decide it can be preserved
as the involved side is removed.

If the tumor is bilateral, the chances of malig-
nancy are increased. Should bilateral cystomas
appear benign, however, it might be particularly
desirable to preserve as much ovarian tissue as
possible. Usually, the appearance of one side
suggests the possibility of resection rather than
of oophorectomy, and it is well to begin on the
side which looks as though the ovarian tissue
would be easier to preserve. If there is no evi-
dence of implantation and there are no adhesions
to the surface, by protecting adjacent structures
with gauze packing, the cystoma can usually be
resected from the ovarian tissue adjacent to the
pedicle and its blood supply. The removed cyst
should then be opened. If the gross appearance
does not suggest malignancy, an attempt should
be made to handle the opposite side in a similar
manner. If the opened cyst shows a grossly
papillary lining, it is better to await the patholo-
gist's opinion concerning the probable malig-
nancy of the neoplasm. If the neoplasm is con-
sidered malignant, the previously preserved
grossly uninvolved portion of the resected ovary,
its adjacent tube, the uterus, the opposite ad-
nexa, and the omentum should be removed.

Some of the less common ovarian neoplasms
present features of unusual interest. The so-
called Krukenberg tumor, for example, always
seems to be remembered, though other more
frequently occurring varieties may have been
forgotten. It is usually bilateral, presents a nod-
ular uneven surface, and is usually free of ad-
hesions. The cut surface shows dense areas alter-

nating with soft myxomatous portions, and, on
histologic section, the characteristic ring cells
are pathognomonic. It is interesting to note that
while Krukenberg1 is generally credited with an
accurate description of both the gross appear-
ance and the histology of this tumor, as originally
reported in 1896, he apparently did not recog-
nize that the tumors were of secondary or met-
astatic nature. Within eight years, however,
others had established the fact that the tumors
Krukenberg had described were usually meta-
static from a primary in the intestinal tract. Per-
haps a “primary” Krukenberg may occasionally
be found. At least, on several occasions, grossly
and histologically typical looking neoplasms
have never developed evidence of a primary
after the ovarian growths were removed.

The incidence of the Krukenberg tumor ap-
proximates 5 per 100 ovarian malignancies. The
practical importance of this tumor is, however,
considerably greater than its incidence indicates.
The mere possibility of this lesion serves to re-
mind us that pelvic neoplasms may be associ-
ated with neoplasms of the bowel. Preoperative
roentgenograms are advisable, and it is often
wise to prepare the patient psychologically, as
well as with antibiotics, for a possible resection
of bowel. A mass, from a clinical standpoint,
considered to be of ovarian origin may, in re-
ality, prove at operation to be of intestinal ori-
gin. This fact quite possibly could be demon-
strated by preoperative roentgenograms, and,
under such circumstances, preoperative prepa-
ration of the bowel with antibiotics would cer-
tainly be desirable. It is well to consider, also,
prophylactic removal of the ovaries when a ma-
lignancy of the bowel, particularly gastric car-
cinoma, is being resected. While this measure
has not been employed sufficiently often to per-
mit its evaluation, at least from a theoretic
standpoint, prophylactic oophorectomy should
be considered as a means of avoiding the sub-
sequent development of Krukenberg tumors.

The so-called functioning ovarian tumors may
have either a feminizing or masculinizing effect
but are often “defeminizing” rather than mascu-
linizing. Among functioning tumors, those with
a feminizing effect predominate in a ratio ap-
proximating 4 to 1. Novak2 has estimated that
granulosa cell carcinoma and the thecomas to-
gether comprise approximately 19 per cent of all
solid malignant growths of the ovary and might
well be suspected whenever relatively solid tu-
mors of the ovary are encountered. In recent
years, reports have suggested that relatively light
irradiation into the pelvis may eventually result
in a significantly increased incidence of femin-

FEBRUARY 1958

55

izing tumors. At present, however, there does
not seem to be a history of irradiation in the
background of a significant number of the pa-
tients in whom granulosa or theca-cell tumors
of the ovary have developed.

When extensive lutein-like changes are evi-
dent, the term luteoma may be employed, but
even when such extensive luteinization is evi-
dent, the biologic effect of such tumors is purely
estrogenic. A present tendency is to regard lu-
teoma as a histologic picture occasionally pre-
dominant in thecomas as opposed to considera-
tion of the luteoma as a separate entity. While
two histologically different neoplasms have been
described, nevertheless, the two may be found
within the same neoplasm. When feminizing
tumors develop in children, “precocious men-
struation" may occur, but it is anovulatory bleed-
ing and such children should not conceive. Evi-
dences of ovulation or the occurrence of preg-
nancy would, therefore, indicate constitutionally
precocious development rather than the develop-
ment of a feminizing tumor.

The malignant potentiality of feminizing tu-
mors remains a question. Novak has suggested
that 25 to 33 per cent of functioning ovarian tu-
mors can be expected to recur at least locally.
Granulosa-cell tumors, though histologically be-
nign, have been reported to recur in the pelvis
fifteen years and more after apparently complete
removal of the primary lesion. In the majority
of instances, when granulosa cell tumors do re-
cur, they do so locally and are clinically of a
rather low grade of malignancy. Occasionally,
granulosa-cell carcinoma may be associated with
the development of abdominal carcinomatosis
and prove rapidly fatal in a manner similar to
primary carcinoma of the ovary. Thecomas are
relatively benign. Feminizing tumors may, how-
ever, contribute in a less direct manner to the
development of malignancy in the female. In
postmenopausal women, the long sustained pro-
duction of estrogen by feminizing tumors occa-
sionally precedes the development of endomet-
rial carcinoma. Thecomas may be particularly
potent in their estrogenic activity and have most
frequently been associated with the development
of adenocarcinoma in the uterus.

Tumors causing defeminization or masculini-
zation may be any of 4 types: (1) arrhenoblas-
toma, (2) adrenal-like tumors, (3) masculinovo-
blastoma, and (4) hilus cell tumors.

The less endocrinologically active tumors, with
a so-called defeminization effect, account for
amenorrhea and regression of the breasts. The
more actively androgenic neoplasms produce
hirsutism, enlargement of the clitoris, and deep-

ening of the voice. Therefore, some type of an-
drogenic tumor might well be suspected when
a woman, previously feminine in appearance,
begins to exhibit changes suggestive of either
defeminization or masculinization. As a general
rule, such changes tend to regress after removal
of the androgenic neoplasm.

The arrhenoblastoma is the classical example
of the masculinizing tumor and histologically
suggests attempts to reproduce testicular tissue.
Many such tumors are nonfunctioning, however,
which observation Novak suggests may indicate
that the smaller, nonfunctioning ones may be
but an embryonic vestige of testicular tissue.
Some of the more undifferentiated arrhenoblas-
tomas have been considered sarcomas.

The adrenal-like tumors of the ovary have
been considered by Novak to be the result of
adrenal cell inclusion within the ovarian anlage,
and they are of importance because their devel-
opment may produce the clinical picture of a
Cushing’s syndrome, similar to that observed
with the development of a tumor of the adrenal
cortex.

The masculinovoblastomas, once called “mas-
culinizing luteomas” are relatively rare — less
than 30 cases have been reported to date. Fre-
quently, the tumors are so small that an adnexal
mass is not evident but, when discovered, appear
encapsuled, present a yellow surface on cut
section, and microscopically suggest a luteoma
or hypernephroma. They are associated with
increased 17-ketosteroids, amenorrhea, hirsutism,
enlargement of the clitoris, and hypertension.

Evidence of defeminization should also sug-
gest the possibility of a so-called hilar cell tumor
of the ovary. These may be particularly difficult
for the clinician to detect, since reported eases
have involved tumors no larger than a normal
ovary. Nests of large ovoid cells similar to the
Levdig cells of the testes may develop in the
medullary portion of the ovary. Though mascu-
linization may develop, it appears without the
hypertension characteristic of the maseulinovo-
blastoma.

Meigs’s3 classical description of the syndrome
which bears his name has undoubtedly stimu-
lated the clinicians’ interest in the possibility of
determining the nature of ovarian neoplasms by
preoperative study of the patient. Meigs’s ob-
servation that benign fibromas of the ovary could
be associated with ascites and hydrothorax has
resulted in many attempts to recognize the en-
tity. Many have considered cystic tumors with
associated ascites and hydrothorax as examples
of this syndrome. The triad of pelvic tumor,
ascites, and hydrothorax has been reported with

56

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benign ovarian cystomas, leiomyomas, teratomas,
malignancies of the ovary, with trauma, and with
carcinoma of the pancreas. Meigs believes, how-
ever, that the syndrome should be restricted to
the triad of: (1) a fibroma-like tumor of the
ovary, (2) ascitic fluid in the abdomen and a
hydrothorax, and (3) disappearance of both the
ascitic fluid and the fluid within the chest after
the ovarian fibroma or fibromas have been re-
moved. He has, moreover, recently re-empha-
sized his criteria, while at the same time giving
credit to two older clinicians who, since Meigs’s
original description, had been recognized as hav-
ing contributed published reports regarding this
syndrome some years previously.

Meigs’s syndrome is so well known that when
internists and roentgenologists recognize hydro-
thorax, they often wonder whether a pelvic neo-
plasm could account for the fluid in the chest.
I have yet to find an unsuspected fibroma of the
ovary when discovery of a hydrothorax was the
first evidence of pathology. We have observed
two typical instances of Meigs’s syndrome, but,
in each instance, there was a clinical suspicion
of ascites, the pelvic tumor was readily identified
on examination, and the hydrothorax was the
last feature of the syndrome to be identified.
The source of the ascitic fluid was long a source
of considerable speculation. It now seems gen-
erally accepted, however, that the fibromas are
edematous and leak fluid into the peritoneal
cavity, from which it finds its way above the
right diaphragm.

Gynecologists of considerable clinical experi-
ence have perpetuated a belief that solid tumors
of the ovary are more likely to cause pain than
cystomas, though, personally, I have yet to see
the patient whose complaint of pelvic pain was
explained by the discovery of a fibroma in her
pelvis.

When the appearance of the cystoma suggests
malignancy and it appears possible to remove
both adnexa and the uterus, it is well to make
as clean and complete an excision as possible.
Excision of parietal peritoneum, particularly in
the cul-de-sac and along the posterior surfaces
of the broad ligaments, usually results in a much
more adequate resection. Exenterations have
taught us that a pelvis so denuded quickly re-
peritonealizes, or a redundant loop of sigmoid
may often be utilized to at least partially cover
the floor of the dissected pelvis. When ovarian
malignancy appears locally invasive, Kottmeier4
has stressed the advisability of saving the uterus.
If involvement of the mesosigmoid and para-
rectal tissues suggests the probability that ex-
cision of the tumor will be incomplete, he be-

lieves it is better to preserve the uterus as a
point from which unremoved tumor can be ir-
radiated. This modification is recommended,
however, only when it is suspected that removal
of the malignant tissue will be incomplete.

In the management of ovarian carcinoma,
some attempt to classify or clinically “stage” the
malignancy would be helpful from a prognostic
standpoint. A simple but clinical and practical
classification would be somewhat as follows:

Stage 1 . Carcinoma limited to one ovary.

2. Carcinoma involving both ovaries but with no
grossly appreciable extension outside the uterus and
adnexa.

3. Ovarian malignancy considered inoperable because
of obvious extension into adjacent tissues.

4. Inoperable ovarian carcinoma with evident carcino-
matosis of the abdomen, involvement of the omentum,
extensive peritoneal implantation, and/or distant metas-
tasis.

The dissemination of ovarian malignancy is
not inhibited by even so much as a peritoneal
covering over the ovary. Early dissemination is
likelv, and the omentum is involved early. Its
removal at the time of initial surgery is a pallia-
tive measure worth consideration, for the de-
velopment of a large “omental cake” often adds
considerably to abdominal distention and dis-
comfort. While fairly extensive pelvic dissection,
including the stripping of parietal peritoneum
off of the bladder, broad ligaments, and cul-de-
sac may contribute to a more complete excision
and a better clinical result when the lesion ap-
pears operable, resection of involved loops of
bowel and heroically extensive surgery in the
pelvis seem to have no place in the management
of ovarian malignancy. The surgeon’s sense of
frustration is based upon the fact that ovarian
malignancy usually and rapidly involves tribu-
taries of the portal system. Extension into the
upper abdomen and liver seems inevitable no
matter how extensive the pelvic excision might
have been.

Occasionally, the surgical procedure may have
been completed before the malignant character
of an ovarian tumor was recognized. When the
diagnosis of carcinoma of the ovary is a post-
operative surprise and only one ovary has been
removed, more adequate surgery should not be
delayed. A second operation, with removal of
the uterus, remaining adnexa, adjacent portions
of the peritoneum, and the entire omentum, im-
proves the possibility of a longer survival.

The effectiveness of postoperative irradiation
is not predictable, but, in the individual case,
its use may seem of great benefit. A full thera-
peutic trial is indicated. The use of intraperito-
neal colloidal gold as a source of irradiation
should be limited to cases in which spill has

FEBRUARY 1958

57

occurred or purely prophylactic irradiation is
considered advisable. If there are any remnants
of tumor in the abdomen, external irradiation is
far more effective. The irradiation from activat-
ed gold may be sufficient to inhibit the reforma-
tion of ascitic fluid, and it is very well tolerated
by the patient, but it seems quite inadequate
when grosslv appreciable foci of tumor indicate
treatment. Recent reports seem to indicate that
some of the newer “nitrogen mustards” are much
more effective when recurrence is evident, and
ascitic or pleural effusion adds greatly to the pa-
tient’s discomfort.

The so-called mesonephric carcinomas of the
ovary continue to be a source of some confusion.
As a rule, this tumor is relatively large, presents
a round, smooth surface, and, on cut section,
appears semisolid except for pseudocystic areas
of degeneration frequently noted within an oth-
erwise smoothly solid neoplasm. The growth
tends to break through its capsule. Malignancy
is evident when penetration of the capsule and
metastatic implantation occur. Metastatic nod-
ules have a noticeably yellow appearance. Ap-
proximately half of the reported cases have been
highly malignant, while many others have evi-
denced a surprisingly benign course. These tu-
mors frequently develop after the menopause
and may be associated with the development of
ascites. The term mesonephroma was first sug-
gested in 1939 by Schiller5 who noted that the
histology suggested rudimentary glomeruli in
some areas. Schiller also noted that this neo-
plasm may also be found as an intraligamentous
tumor, which characteristic has been particu-
larly emphasized by Gardner and associates/’
The latter have recognized, however, that these
neoplasms are of mesonephric rather than of
ovarian origin.

The various tvpes of neoplasms arising in the
female pelvis, which were thought to be of me-
sonephric origin, have recently been described
by Novak7 as follows:

1. The classical mesonephroma of Schiller, which may
seem to be arising in the ovary.

2. The clear cell carcinomas of the ovary, which may
coexist witli or develop within a mesonephroma.

3. Tire mesonephric tumors developing within the
broad ligament.

4. Cervical and vaginal tumors of mesonephric origin.

When the latter develop in the cervix, the his-
tologic appearance suggests a cystadenoma or
an adenocarcinoma. Development of the more
myxomatous of the mesonephric tumors within
the vagina may result in a papillary growth con-
fused with sarcoma botryoids.

Increased knowledge of the nature of ovarian
neoplasms and improved management of the

patients affected are unfortunately evident only
when the neoplasms are benign. To date, little
progress has been made toward decreasing the
number of deaths due to ovarian malignancies.
As we contemplate possible approaches to this
problem, the futility of frequent and periodic
routine pelvic examination might well be recog-
nized. Annual pelvic examination appears to
offer little hope of detecting malignancies of the
ovary in a curable state. During the years Mac-
farlane* and her co-workers repeatedly examined
a number of volunteers who came in regularly
every six months or every year, among 18,000
such routine examinations, 6 carcinomas of the
ovary were detected. Among the 6, onlv 1 was
considered early enough to be curable. Every
study of this problem emphasizes the rapidity
with which ovarian malignancy progresses to an
inoperable stage. Available data suggest the
probability that, if all women were examined
once a year, an ovarian malignancy would have
developed in approximately 3 among each 10,000
during the year, but that only 1 of the 3 neo-
plasms would be in a favorably early stage of
its development.

Small wonder then that there is an increasing
tendency to take out ovaries on a prophylactic
basis. The risk of leaving the ovary at the time
of hysterectomy has been the subject of consid-
erable discussion. Grogan and Duncan,9 of Bos-
ton Free Hospital, stated that complaints or a
pelvic tumor developed in 33 per cent of patients
with ovaries preserved at the time of hysterec-
tomy, which was regarded as evidence that the
ovaries should have been removed. Fagen and
associates,10 of Chicago Presbyterian Hospital,
found that 7 per cent of 172 women who came
into their hospital for treatment of an ovarian
carcinoma had previously had a pelvic laparoto-
my at which time the ovaries might have been
removed. Such observations suggest the advisa-
bility of attempts to calculate the risk of preserv-
ing the ovary.

Among the 9 per 1,000 women now destined
to develop an ovarian carcinoma, we might well
ask — how many of those ovarian carcinomas
could we prevent by removing both ovaries each
time a hysterectomy is indicated? This obvi-
ously woidd depend upon the incidence of hys-
terectomy, but, if it is 10 per cent, we coidd
reduce the over-all incidence of ovarian carcino-
ma by 10 per cent, that is, from 9 to approxi-
mately 8 cases per 1,000 women simply bv re-
moving both ovaries each time a hysterectomy
is indicated. We would expect the incidence of
ovarian carcinoma, among women previously
subjected to hysterectomy, to be the same as

58

THE JOURNAL-LANCET

among the population at large, namely., approxi-
mately 9 cases per 1,000 women. Actually, Allen
followed 2,097 women to see how many had de-
veloped a carcinoma of their preserved ovaries
and found not the 19 cases we would expect in
such a group from the incidence of ovarian ma-
lignancy among the population at large but 63
cases, an incidence 3 times what we might ex-
pect. Well might we ask: (1) If women subject-
ed to hysterectomy are predisposed to the for-
mation of malignant neoplasms of the ovary by
changes which follow hysterectomy? (2) if the
same benign uterine neoplasms or the loss of
uterine support or the hemorrhagic menstrual
tendencies— which originally indicated hysterec-

REFERENCES

1. Krukenberg, F.: Ueber des Fibrosarcoma Ovari Mucocellu-

lar ( Carcinomatodes ). Arch, gynak. 50:287, 1896.

2. Novak, E.: Hormone-producing ovarian tumors. Obst. &

Gynec. 1:3, 1953.

3. M^igs, J. V.: Pelvic tumors other than fibromas of ovary

with ascites and hydrothorax. Obst. & Gynec. 3:471, 1954.

4. Kottmeier, H. L.: Classification and treatment of ovarian

tumors. Acta obst. et gynec. scandinav. 31:313, 1952.

5. Schiller, W.: Mesonephroma ovarii. Am. J. Cancer 35:1,

1939.

6. Gardner, G. H., Greene, R. R., and Peckham, B. M.:
Normal and cystic structures of broad ligament. Am. J. Obst.
& Gynec. 55:917, 1948.

tomy among these women— resulted in a greater
than average incidence of ovarian malignancy?
or (3) Is such sampling inadequate? Should such
figures be regarded as significant?

The answers to many such important ques-
tions await data that careful observation should
eventually provide. Since, at the present time,
there seems to be no means of recognizing which
women are predisposed to the development of
ovarian carcinoma, the question remains one of
deciding whether a 1 per cent chance of a ma-
lignant tumor of the ovary justifies prophylactic
oophorectomy when laparotomy is performed for
other indications and the woman is approaching
her climacteric.

7. Novak, E.. Woodruff, J. D., and Novak, E. R.: Probable

mesonephric origin of certain female genital tumors. Am. J.
Obst. & Gynec. 68:1222, 1954.

8. Macfarlane, C., Sturgis, M. C., and Fettefman, F. S.:
Results of experiment in control of cancer of female pelvic
organs and report of 15-year research. Am. j. Obst. & Gvnec.
69:294, 1955.

9. Grogan, R. H., and Duncan, C. J.: Ovarian salvage in rou-
tine abdominal hysterectomy. Am. J. Obst. & Gynec. 70:
1277, 1955.

10. Fagen, G. E., Allen, E. D., and Klawans, A, H : Ovarian
neonlastns and repeat pelvic surgery. Obst. & Gynec. 7:418,
1956.

Benign congenital hypotonia in infants may be manifested by generalized
weakness of the skeletal muscles. The nonprogressive congenital neuromus-
cular abnormality should be differentiated from amyotonia congenita. Phys-
ical examination shows that the child is limp. Neuromuscular development is
delayed. Weakness may be greater in some muscle groups or may be uniform
throughout the trunk and limbs. No pseudohypertrophy is observed.

Electrical testing of muscles bv the faradic-galvanic method reveals no
abnormality; electromyograms show excessive polyphasic and short-duration
potentials during voluntary contraction of affected muscles. No pathogenic
alterations are observed in muscle biopsy specimens.

In 8 children with benign congenital hypotonia who recovered completely,
fetal movements had been normal. The deep tendon reflexes could be elicited
but were sometimes diminished. Intellectual development was normal. Muscle
tonus returned to normal bv the fifteenth year of life or before.

In 9 patients, symptoms were more severe; fetal movements had been
reduced in 1 case. Deep tendon reflexes were lacking in 3, depressed in 4,
normal in 1, and brisk in 1 patient. Intercostal weakness was noted in 3 in-
stances. Some muscular weakness persisted in these patients.

John N. Walton, M.D., National Hospital, London. 1. Neurol., Neurosurg. & Psycbiat. 20:144-
154, 1957.

FEBRUARY 1958

59

Colic in Infancy

CHARLES E. SNELLING, M.D.
Toronto, Ontario

Colic in infancy is one of those very useful
terms like “Hu” and “constitution,” which are
very specific diagnoses in the minds of the laity
but very broad in their compass when used by
the profession. When this diagnosis is made, it
is accepted by the parents and they know that
it is something they must “put up with” for three
to five months and that the child will recover.

Colic has been defined in some texts by a
description of the symptomatology as a condi-
tion characterized bv crying, drawing the legs
up, distention of the abdomen, and expulsion of
gas by mouth, rectum, or both. These same ar-
ticles also state that the condition usually lasts
three to five months. The first time the term
came to my attention, shortly after entering
practice, was from a grandmother who sagely
stated the new baby had “three months' colic.”
Although it may be necessary to use this term
or so-called diagnosis, it is a mistake to accept
the situation as inevitable. From personal ex-
perience, it has frequently been possible to find
other solutions for the etiology.

The causes of feeding or nutritional disturb-
ances in infancy may be divided into some 7
categories. In order of their frequency they are:

1. Infections, acute or chronic

2. Congenital anomalies and incidents associ-
ated with birth

3. Environmental conditions

4. Feeding disturbances, quantity or quality

5. Psychoneurotic disturbances

6. Allergy

7. Endocrine and metabolic disturbances
Infections. The onset of infection is the most
common cause of “colic," abdominal distention,
and so forth in a previously healthy infant with
uneventful feedings. Infections account for the
largest number of digestive disturbances.

Congenital anomalies. Congenital anomalies
involve anv part of the body. Those of the heart
are frequently associated with symptoms attrib-

charles e. snelling is associate professor of pedi-
atrics at the University of Toronto and The Hospital
for Sick Children, Toronto.

Read at the Canadian Medical Association meet-
ing in Edmonton, Alberta, June 19, 1957.

utable to the gastrointestinal tract, which could
be called “colic.” The gastrointestinal tract fre-
quently has stenosis, bands, or malrotation which
may produce these symptoms. One of the most
frequently overlooked is the rectosigmoid region.
Two conditions in this area require special em-
phasis.

The history of a baby reveals spells of crying,
distention, and gas, which are often associated
with meals. This fussy period occurs after meals
and often is associated with some straining and
attempts at evacuation which may be successful.
If one asks if there is trouble with bowel move-
ments, the answer is frequently “No, the baby
has frequent passages.” The character of the
movement may be loose or ribbon-like. This in-
formation is obtained only by direct questioning.
Rectal examination should always be done on a
“colicky” baby unless an adequate cause for the
condition can be found otherwise. The first con-
dition that may be found is a tight fibrous rectal
opening about the size of a lead pencil. The
rectum in a young baby need not be larger than
this, but it may be dilated slowly to the size of
a small index finger. In this condition, there is
a fibrous ring inside the sphincter. When this
has been stretched, in many instances, the “colic”
immediately clears. It is frequentlv necessary to
dilate the rectum on two or three occasions sub-
sequently at weekly intervals.

The second condition found in this area is the
so-called redundant sigmoid. The descending
colon usually curves to the right across the pelvis
and then back to the rectum. In this type of
case, the sigmoid curves across to the right, then
down into the pelvis, back up, and down into the
rectum, forming a very sharp S curve similar to
a sewer trap. Examination by rectum reveals an
emptv area in the rectum, but fecal matter can
be felt in the pelvis in the bowel immediatelv
adjacent to the rectum and packed well into the
pelvis. After advancing the finger up around the
first bend, a large quantity of stool is immediate-
lv released. In this type of case, the mother in-
variably says that the baby has regular move-
ments, but the fact is that the baby is one or
two days late. The stool that is passed today is
pushed along by the fecal material behind it so

60

THE JOURNAL-LANCET

that the baby’s sigmoid and colon are constantly

full.

This condition invariably rights itself as the
baby’s trunk becomes elongated, thus pulling the
sigmoid out of the pelvis, but it may last as long
as two years. This type of patient is relieved
by an enema of baking soda, M to 1 tsp. in 4 to
10 oz. of water. This straightens out the trap-
like effect in the rectosigmoid and usually gives
relief for about two days if the enema has been
effective. Suppositories or soap sticks should
never be used. They only make the condition
worse and possibly lead to the development of
prolapse. An unexplained but frequently dra-
matic procedure in treatment of this condition
is the use of the barium enema. It is possible
that the heavy solution and pressure with palpa-
tion and manipulation necessary to properly vis-
ualize the bowel forces the sigmoid out of the
pelvis and straightens it. Invariably, when the
barium enema is administered correctly, the
radiologist is unable to demonstrate the sigmoid
colon packed down in the pelvis, but, peculiarly
enough, the child’s symptoms nearly always dis-
appear after this procedure. This is a situation
in which a diagnostic measure acts in a thera-
peutic way similar to the demonstration and re-
duction of intussusception.

Incidents associated with birth, such as cere-
bral damage from hypoxia, edema, or hemor-
rhage, are frequently unrecognizable in the early
period of life. It has been the experience of ail
pediatricians to discover after six months or a
year that a baby who is high-strung and cries
all the time is mentally retarded because of cere-
bral palsy. Many of these infants were treated
for colic, hypertonia, and other conditions until
the true underlying cause became manifest.
There is no way of recognizing mental deficiency
in the first few months of life except, possibly,
from an electroencephalogram, but every crying
baby could not be subjected to this procedure.
However, with a history suggestive of some
problem at the time of birth, the possibility of
an abnormal mental condition should be kept in
mind. In addition, unrecognized fractures may
cause symptoms suggestive of colic.

Environmental conditions. If environmental
conditions were successfully eliminated, pediat-
rics in this country would certainly become en-
tirely a consulting practice.

These conditions include the way the baby
is handled and fed, the temperament of the
others in the home, the home itself, and all the
other things which impinge on this new life
which has been taken from a place of complete
protection in the uterus to one where it must

fight against outside factors for its very exist-
ence. True, this struggle is aided by others, such
as parents, nurses, and doctors, but their efforts
may produce stimuli which upset the baby.
These elements are the largest cause of colic in
the very young baby.

Temperature and humidity are usually not big
factors. The most frequently encountered prob-
lem occurs in the artificially fed baby. Mothers
have read the books and are impressed by the
danger of a nipple with too large a hole. Nipples
are invariably sold with holes in them so small
that even a husky grown man would have diffi-
culty in extracting a feeding. The mothers say
the feeding goes fast enough. Even heat the
bottle up and turn it over and a spurt of liquid
is seen. However, after that first fluid goes out
due to the pressure of the heated air in the
bottle, nothing follows. One is always impressed
by the size of the nipple holes in nurseries and
pediatric wards where the nurses do not have
all day to feed a baby. The babies do not have
colic or do they choke on or vomit feedings if
fed intelligently. The mother should be instruct-
ed how to use the bottle properly, and it is well
to give a practical demonstration. The nipple
should have dual holes large enough to see
through each a letter about the size of a small
“o” on an ordinary typewriter. Even if the feed-
ing pours through the nipple, as it sometimes
does in nurseries, nothing untoward happens
if it is removed from the baby’s mouth after a
bubble or two to give the baby a chance to
breathe. The small-holed nipple leads to air
swallowing, colic, and vomiting. This simple
procedure usually endears the pediatrician to
the family for life, since, after many sleepless
nights, the parents are greatly relieved to have
a quiet, satisfied baby.

The next type of disturbance might be termed
“paternal colic.” Pediatricians find that much
of their practice related to this condition comes
in the evenings or weekends. This is partly due
to the fact that the father is home at such times,
and, wishing to have his share of the new baby,
handles the infant more than he should. Another
situation causing this type of colic occurs when
the father becomes annoyed when his comfort
and relaxation are disturbed. The mother then
becomes tense, and the baby is quick to sense
this reaction. At this point, the father is impa-
tient and sends for the doctor.

This is the period of unexplained evening fussy
session, which many babies have from 6 to 10
p.m. In breast-fed babies, one can say that the
mother is tired or not producing sufficient food,
but it occurs in nonbreast fed babies as well.

FEBRUARY 1958

61

Another possibility is that a time of increased
activity of the mother during fetal life may have
conditioned the baby. Another possibility is the
increased tension, activity, and noise in the home
when the father and other children are there.
This is a condition that has no adequate ex-
planation or cure. The parents should be told
that they are fortunate that this period does not
occur from 10 p.m. to 2 or 6 a.m.

Tense parents can generate tension in the baby
by constantly fussing over him. It is frequently
a good therapeutic measure to take the baby out
of his environment on the pretext of making
tests or trying new feedings. After a few days
of rest, parents often settle down and have a
perfectly tranquil child.

Overcrowding and housing conditions have
led to much so-called colic. When the family
live with in-laws or in flats or apartments, fear
of disturbing others is cause to pick the baby
up when he cries. When put down, he cries
again. This is a conditioned situation, which
can, of course, be cured by moving to a sepa-
rate dwelling and allowing the baby to cry it out.

In all of these situations, it is often necessary
to give the baby a sedative, such as % gr. of
phenobarbital and 1/1200 gr. of atropine before
meals, for a while. Frequently, the parents need
the sedative, but a quiet baby nearly always
reacts indirectly on the parents. It has also been
observed, in some instances, that when the baby
settles down, the mother then becomes worried
because he is too quiet. Little can be done with
this type of parent.

Colic is also caused by such factors as pins
pricking the baby, soiled clothes, too warm
or too cold an environment, too much clothing,
and so forth.

Feeding disturbances. Feeding is more fre-
quently wrongly blamed for colic than any other
cause. Except for quantity, it usually does not
cause distress. At the present time, a knowledge
of adequate feeding is so universal from med-
ical advice, press periodicals, and advertising by
the food companies that it is most unlikelv for
a baby to receive a feeding which is qualitatively
inadequate. Thus, if an artificially fed baby is
upset, it is not the feeding that is at fault but
the baby. An unusual feeding may be necessary
in some instances. It is most important to em-
phasize these facts to the parents, and this ap-
proach may also save the phvsician some embar-
rassment. Breast milk also, for practical pur-
poses, causes no qualitative disturbance. Over
many years, we have known of only two infants
who coidd not take breast milk in spite of the
fact the mothers had large quantities.

Quantitative disturbance is very common, par-
ticularly in the breast-fed infant. Underfeeding
in these infants is characterized bv vomiting,
colic, gas, and frequent bowel movements. The
gas that is swallowed, plus the hunger, cause
the first symptoms, and the frequent movements
are a result of passages of intestinal juice from
the rectum. The baby does not gain weight.
This condition is corrected by increasing the
breast milk supply, if possible, by increased
stimulation and the use of a supplementary feed-
ing. It is frequently necessary to put the baby
on an artificial feeding entirely.

Overfeeding in the breast-fed baby causes a
similar set of symptoms: vomiting, colic, gas, and
frequent movements. In this situation, the move-
ments are large and the baby usually has had a
rapid gain in weight. This condition can be cor-
rected by cutting down the feeding by allowing
the baby less time at the breast. Most babies
who suffer from this disturbance are large, vig-
orous, and nurse too rapidly. A small amount
of water, ’2 to 1 oz., given before feeding time,
usually corrects the trouble. It is not wise to try
to force the mother to curtail the number of
feedings because law of supply and demand
nearly always works out a solution in a week or
two. If the physician interferes, the mother often
cuts down the nursing time too drastically with
a result that soon there is no breast milk.

Underfeeding and overfeeding in the artifi-
cially-fed infant may produce the same symp-
toms, but this is very unusual.

Psychoneurotic disturbances. Among the psy-
choneurotic disturbances are hypertonia and
idiopathic colic. Hypertonia is characterized by
a crying, high-strung, vomiting baby with all the
symptoms of colic. The true hypertonic baby is
relieved with atropine, with or without pheno-
barbital, before feedings.

Idiopathic colic supposedly lasts three to five
months and is the disturbance for which a cause
cannot be found. This group of infants is fairly
small.

Allergy. Food allergy is not an infrequent
cause of colic. There may be other symptoms,
such as vomiting and/or diarrhea. The cause is
difficult to determine and, I feel, frequently over-
looked. The condition can be corrected by chang-
ing the feeding from cow’s milk to goat’s milk
or to preparations such as soybean suspensions
and protein hydrolysates.

Endocrine and metabolic disturbances. In
endocrine and metabolic disturbances, feeding
difficulties are occasionally seen, some of which
have the symptomatology of colic. Tetany is
frequentlv manifested by a very irritable, high-

62

THE JOURNAL-LANCET

strung babv. In cases of delayed so-called tetany
of the newborn, these may be the only symp-
toms for some time. In the adrenogenital syn-
drome, symptoms of colic often occur both in the
prerecognized stage and posttreatment phase.

The symptoms of scurvy might be misinter-
preted as colic. The baby is irritable and cries,
particularly when handled. This condition is due
to lack of vitamin C and is increasing. We have

30 to 50 cases a year at The Hospital for Sick
Children.

The foregoing are some of the conditions that
may give rise to symptoms called colic. One can
see that many must be eliminated before it can
be said that a child has colic. Many of these
conditions are amenable to treatment. It is con-
sequently important to carry out a careful dif-
ferential diagnosis.

After bacterial meningitis has been successfully treated in infants and
children, subdural effusion may lie due to excessive withdrawal of cerebro-
spinal fluid for diagnostic purposes.

In children, 10 to 15 ce. of spinal fluid represents one-fifth to one-third
of total fluid volume. Withdrawal of this amount of spinal fluid may cause
separation of the dura from the arachnoid, with tearing of the bridging veins
in the subdural space and consequent subdural hematoma. When this blood
liquefies, osmotic tension draws spinal fluid into the subdural space. Probablv,
onlv 1 tap should be done and no more than 3 cc. of fluid removed.

When the fluid withdrawn was limited to 3 ec., only 3 of 27 patients had
subdural effusions. In contrast, effusion occurred in 9 of 20 infants from
whom larger volumes of fluid were withdrawn.

Jonathan M. Williams, M.D. and Harold Stevens, M.D., Children’s Hospital, Washington,
D.C. J. Intemat. Coll. Surgeons 27:590-594, 1957.

Pregnant women undergoing valvotomy for correction of mitral stenosis are
in no greater danger than those in the nongravid state in whom the operation
is performed. Therefore, the procedure should he done if pulmonary conges-
tion or edema persists or recurs despite treatment with salt-free diets, complete
bed rest, and mercurial diuretics.

Pulmonary edema is the most important cardiac cause of death in pregnant
women. During pregnancy, increased demands are made on the cardiovascular
svstem because of salt and water retention, rise in blood volume, and aug-
mented cardiac output. Healthy women tolerate the demands, hut patients
with mitral stenosis have considerable rises in left atrial and pulmonary capil-
lary venous pressures.

In 18 pregnant women with mitral stenosis, some of whom were near
death, valvotomy was performed with good results; none of the women died
or had significant postoperative complications related to the pregnancy. Op-
eration apparently caused premature births in 2 instances, and 1 fetus did
not survive.

R. J. Marshall, M.D., and J. F. Pantridge, M.D., Royal Victoria and Roval Maternity hospitals,
Belfast, Ireland. Brit. M. J. 5027:1097-1099, 1957.

FEBRUARY 1958

63

Aii Anesthesiologist’s Approach to Prevention
of Operating Room Deaths

VALENTINO D. B. MAZZIA, M.D.

New York City

Numerous studies1-3 detailing the mortality
associated with surgery and anesthesia have
appeared. Although valuable, these studies have
not provided the practitioner with a regimen
which if followed would tend to decrease the
incidence of cardiac arrest. An excellent study
by Berne and associates4 contains an outline of
the known causes of cardiac arrest. However,
the most fruitful approach is to study isolated
instances in which the cause of death is readily
ascertainable and preventable in the light of
present knowledge and technics and, in turn, to
develop from such a study a program for the
prevention of operative deaths.

From the time the anesthetist is first asked to
assist in the care of a patient until he himself
decides that his services are no longer needed,
many opportunities arise to apply medical acu-
men anesthesiologically in the prevention of op-
erating room deaths. The anesthetist must de-
velop a medical routine exactly as every other
physician does. Such a routine approach should
include the following:

1. Establishment of a physician-patient rela-
tionship.

2. An adequate history of anesthesiologically
relevant material.

3. Proper evaluation of the physical examina-
tion.

4. Pertinent laboratory studies.

5. Preoperative preparation.

6. Extremely close attention to the effects of
drugs which are administered with appro-
priate mechanical and pharmacologic anti-
dotes at hand.

7. Maintenance of the physician-patient rela-
tionship until no further care is required.
Should any of these established steps be ig-
nored, unnecessary death will residt.

Before elaborating on these phases of patient
care, a note on consultation is in order. With

valentino d. b. mazzia is assistant attending anes-
thesiologist at The New York Hospital and assistant
professor of clinical anesthesiology in surgery at
Cornell University Medical College, New York City.

respect to consultation, the agent per se is hardly
ever the determinant of whether the patient sur-
vives. It is the skill of the administrator rather
than the drug he administers that decides the
question of life or death. Unfortunately, many
surgeons and internists are not aware of this
point. The following death illustrates the point.

A 4-year-old boy with known congenital heart dis-
ease was scheduled for filling of deciduous teeth. Pen-
tothal administered by skilled anesthesiologists had
been used twice uneventfully for diagnostic cardiac
studies. The private pediatrician felt that this child
could “take” an anesthetic. A technician administered
rectal Pentothal, sat the child in a dental chair, and
because of restlessness continued with opendrop ether.
After one and a half hours in the chair under ether-air,
the heart stopped. At autopsy, cor triloculare was found.
The administrator and not the agent was to blame in
this case.

Let us go back to the medical routine. First
is establishment of a physician-patient relation-
ship. EckenhofF reports 4 deaths in a ten-year
period at the University of Pennsylvania which
were, in all probability, due to apprehension.
The mechanism of death is obscure, but the
danger is real. The patient’s mental and emo-
tional outlook must be evaluated in advance,
and he must be given premedication in such a
fashion that he comes to surgery at ease. Pa-
tients must be seen as early before operation as
possible.

Second is an adequate history of anesthesio-
logically relevant material. This history must
usually be taken by the anesthetist because the
importance of some of the information, which
means life or death to the patient, is unknown
to internists, surgeons, obstetricians, and pedi-
tricians. For example, what history ever includes
an account of the tvpe of anesthesia a patient
has had in the past? Fortunate is the anesthetist
who can refer back to previous anesthetic rec-
ords which, let us hope, were complete and ac-
curately kept, to learn of a patient’s sensitivity
to premedicants, barbiturates, or depth of anes-
thesia. Often the patient says that he went into
shock after a previous anesthetic or that pulmo-
nary edema developed. This information is vital.

64

THE JOURNAL-LANCET

Eekenhoffr' reports the case of a patient who had
had severe hypertension during a previous sur-
gical procedure and who died after a second
operation. At autopsy, an unexpected pheochro-
mocytoma explained everything.

Another major aspect of the history that must
he obtained is a knowledge of the previous medi-
cation the patient has taken. The drugs which
are important to anesthetists are constantly
changing as new drugs are introduced or as
antidotes to old drugs are found. Until recently,
cortisone administration any time within six
months before surgery was considered an indi-
cation for preoperative medication with cortisone
in order to avoid possible postoperative adreno-
cortical insufficiency. With the development of
intravenous hydrocortisone, which acts very rap-
idly, preoperative cortisone is not necessary
unless the postoperative differential diagnosis
of adrenocortical insufficiency can be confused
with the usual postoperative course, as in cra-
niotomy and thoracotomy. If reserpine has been
given anv time within ten days previous to ad-
ministration of an anesthetic, profound hypoten-
sion may follow with cardiovascualr collapse
and, possibly, death. Other drugs of interest are
chlorpromazine and promethazine. Both of these
drugs interfere with cardiovascular compensa-
tory mechanisms and in overdosage can produce
seizures. An uncommon but important problem
is that of the patient who has had his pituitary
removed in toto for carcinoma or diabetes mel-
litus and, as a result, diabetes insipidus has de-
veloped. Such a patient will be on self-adminis-
tered Pitressin snuff. It is important to discon-
tinue Pitressin at least five to eight hours before
surgery. Thus far, we have had to anesthetize
2 patients in both of whom we were fortunate
enough to discontinue the Pitressin in time. The
anesthetist must obtain and evaluate the pre-
operative history of drug intake. Of course, car-
diovascular, respiratory, and metabolic functions
must be fully appraised.

Third is proper evaluation of the physical ex-
amination. Again, the anesthetist is concerned
with information which is seldom on the chart,
and life may be threatened if it is unavailable.
Maintenance of the upper airway is a special re-
sponsibility. The following illustrates this point.

A 64-year-old male with a tumor of the nasopharynx
was on the operating table for tracheotomy because of
progressive dyspnea and cyanosis due to obstruction of
the upper airway. To control agitation, the anesthetist
I administered 200 mg. of thiopental. The patient lost
consciousness, the airway became completely obstructed,
and he expired before the tracheotomy could be accom-
plished. The error here was administration of a general
anesthetic before the airway was secured.

In this part of the evaluation, the major danger
of emergency anesthesia must be faced, namely,
the full stomach, whether from ingestion of food,
hemorrhage, or intestinal obstruction. The most
common explainable cause of anesthetic death is
vomiting or regurgitation with aspiration and as-
phyxia. This complication may be managed
either by establishing a secure airway with a
cuffed endotracheal tube before the induction of
general anesthesia or by emptying the stomach
before the patient is subjected to general anes-
thesia. Some recommend a nasogastric tube with
a large cuff drawn up against the cardiac sphinc-
ter.

In a case of multiple trauma, intracranial in-
jury or thoracic injury may be first diagnosed by
the anesthetist, especially if the physician in
charge of the patient is devoting all of his atten-
tion to a different area of the body. If either of
these injuries goes unrecognized and an anes-
thetic is administered, let’s say for repair of a
fractured lower extremity, the patient may die
suddenly on the table. Although the following
case is not clear-cut, we feel that death was
caused by superimposing the toxic effects of a
general anesthesia on a cerebral concussion.

A 32-year-old male received a severe beating about
the head while intoxicated. After spending twelve hours
at home, lie walked to the hospital in a daze. Thirty-
six hours after injury, repair of his fractured mandible
was scheduled. A nasotracheal tube was passed under
local anesthesia, and surgery was begun under Pentothal,
nitrous oxide, and oxygen. After one hour of surgery,
the heart stopped. The airway had always been perfect,
and an overdose of anesthetic agents was not apparent.
Autopsy revealed nothing.

The patient’s physical state should be inspect-
ed carefully immediately before the administra-
tion of the anesthetic. Everyone knows of pa-
tients who died in the anesthesia induction room
while waiting for the anesthetist to arrive.
A myocardial infarction may occur at any time.
The sudden onset of signs of congestive heart
failure in the greater or lesser circulations or of
a cardiac arrhythmia is cause for delaying the
surgery until a diagnosis has been established
and the condition has been controlled. The fol-
lowing case illustrates that an anesthetic admin-
istered to a patient with recent cardiac arrhyth-
mia caused her death.

Operation in a 65-year-old white female with carci-
noma of the rectosigmoid was cancelled because an
irregular pulse was noted in the induction room, although
previous electrocardiograms had indicated a normal sinus
rhythm. Further medical evaluation for three days re-
vealed little, since her rhythm again became regular.
Brought up again for surgery, an irregular rhythm was
noted and it was decided to go ahead with ether anal-
gesia. After three and one-half hours of surgery, the
jieart stopped and could not be resuscitated.

FEBRUARY 1958

65

Should there be history of asthma or allergy,
it is incumbent on the anesthetist to listen to the
lungs and to determine the immediate preopera-
tive status of the bronchiolar musculature. At
this point, a word on relative and absolute con-
traindications to anesthesia is in order. We feel
there are never contraindications to essential
emergency surgery, provided the personnel are
competent, anesthesia and surgical equipment
are available, and the patient is prepared as com-
pletely as possible.

There are absolute contraindications to elec-
tive surgery, such as recent myocardial infarc-
tion, acute infectious hepatitis, and relative con-
traindications, such as pulmonary insufficiency.
However, again one prepares the patient and
balances the risk of anesthesia against the neces-
sity of surgery.

The hemoglobin and the hematocrit are cru-
cial. We all know of the soldiers who died be-
cause of rapid administration of Pentothal in
the presence of latent or incipient shock. We are
all aware in civilian life of the syndrome of
chronic shock. In this syndrome, the blood vol-
ume is considerably reduced, but the vascular
system is correspondingly constricted so that
apparent compensation with normal hemoglobin
and hematocrit values exists. However, upon the
administration of a general anesthetic or of a
subarachnoid block, the vasoconstriction is lost
and there is a pronounced deficit in the circu-
lating blood volume. Such patients die because
of hemorrhagic shock. It is even possible in this
situation to set into motion a chain of events
which are practically irreversible.

A 40-year-old woman with terminal carcinoma of the
breast was scheduled for total removal of the pituitary.
Preoperative hemoglobin was 9.1-gm. per cent, and red
blood cells were 2.8 million per cubic millimeter. With
the induction of general anesthesia, consisting of Pento-
thal, oxygen, ether, and Arfonad, her respirations became
shallow, pulse weak, and blood pressure precipitously
fell to a systolic of 60 mm. Hg. All anesthetic agents
were discontinued. Five hundred cubic centimeters of
whole blood were administered rapidly, and oxygen was
Hushed repeatedly. In spite of these measures, heart
action ceased twenty minutes after all anesthetic agents
were discontinued. An irreversible chain of events had
been set into motion in this hypovolemic, myelophthisic,
pancytopenic patient.

Another major consideration is the tempera-
ture. In children, general anesthesia often pro-
duces heat retention which, when added to car-
bon dioxide retention, hypoxia, and to the cere-
bral irritant effects of the agent itself, may result
in convulsions and death. We feel so strongly
about fevers in children that elective surgery in
a child with a fever is always deferred. We
never lower the temperature artificially and then
proceed with surgery. In the case of emergency
surgery, the temperature is controlled by a water
mattress, and the temperature must be lowered
before anesthesia is induced.

Fifth is preoperative preparation. If the pre-
vious four steps are carried out properly, the pre-
operative preparation becomes a logical out-
come. In essence, the object of preoperative
preparation is to improve the physical status of
the patient to the optimum possible point. We
can not cure many conditions, but we can often
restore compensation. In the case of dehydra-
tion and electrolyte imbalance, we begin hy-

Fig. 1. Bag and mask provide
oxygen ventilation. The op-
erator is entering the chest to
perform cardiac massage.

66

THE JOURNAL-LANCET

drating before surgery. In the case of decreased
pulmonary function due to chronic emphysema
with superimposed bronchiolar constriction and
infection, the infection can be partially cleared
up preoperatively and the bronchiolar constric-
tion relieved. The patient in cardiac decompen-
sation can be digitalized. Certainly, in such
cases, our role as physicians first and anesthesi-
ologists second becomes readily apparent.

Six, extremely close attention to the effects of
drugs which are administered and appropriate
mechanical and pharmacologic antidotes avail-
able. We feel that no anesthesia, local or gen-
eral, should ever be administered without certain
minimum equipment at hand and 2 individuals
who are competent to perform resuscitation.
Figure 1 illustrates the type of equipment that
we feel is necessary. Briefly, it includes a means
of administering oxygen under positive pressure
and a means of entering the chest to perform
cardiac massage if necessary. Note that an endo-
tracheal tube is not necessary. Figure 2 shows
that even the oxygen and the mask may not be
necessary. Usually, in this group, deaths occur
because of a belief that the agent or technic is
so safe that no resuscitation whatsoever is ever
needed. For example, in New York, a 20-vear-
old healthy woman expired suddenly after local
injection of 8 cc. of 2 per cent procaine for a
tonsillectomy. No resuscitative efforts were
made. Autopsy was unremarkable. Many pro-
cedures are done under local anesthesia with
no equipment at hand and without 2 people in
attendance who know how to resuscitate. Sooner
of later this neglect leads to unnecessary death.

The other major causes of anesthetic deaths are
absolute or relative overdose of the anesthetic
agent, asphyxia, and reflex cardiac arrest. Al-
ways, prevention depends upon the knowledge
and skill of the anesthesiologist who administers
anesthetic drugs and his close attention to the
response of the patient so that an overdose can
be avoided, oxygen supplied, and carbon dioxide
eliminated.

Last is maintenance of the physician-patient
relationship until no further care by the anes-
thesiologist is required.

The anesthetist’s responsibility does not cease
after the operation. At this time, some problems
fall directly into his province. The patient who
has had a thoracotomy may have a potential ten-
sion pneumothorax. The patient who has had a
nephrectomy or adrenalectomy may have a pneu-
mothorax. It is our practice to transport all pa-
tients who have had thoracotomies from the op-
erating room to the recovery room under oxygen.
The anesthetist must give advice concerning
postoperative sedation and analgesics. Failure
to do so may result in death from an overdose
of morphine. The anesthetist must determine
when he can turn the care of the patient over
to someone less skilled. This decision may be
difficult but should always be conservative. The
anesthetist must stay with the patient as long
as necessary, even if it means delaying the op-
erating room schedule. Many deaths occur in
the postoperative period and, most often, they
occur in an unobserved patient. These can be
frequently ascribed to asphyxia caused by a poor
airway.

FEBRUARY 19.58

67

In conclusion, I would like to stress the im-
portance of studying very closely every death
that occurs in the operating room. In our own
community, these studies go on at various levels
from the day of death and last indefinitely. First,
an autopsy is almost always mandatory before
we can with any certainty state the cause of

REFERENCES

1. Beecher, H. K., and Todd, D. P.: Study of deaths associated
with anesthesia and surgery based on a study .of 599,548
anesthesias in 10 institutions, 1948-52, inclusive. Ann. Surg.
140:2, 1954.

2. Edwards, G„ Morton, H. J. V., Pask, E. A., and Wylie,

W. D. : Deaths associated with anaesthesia — report on 1 ,000

cases. Anaesthesia 11:194, 1956.

3. Stephenson, H. E„ Jr., Reid, L. C., and Hinton, J. W.:

death. The death should be reviewed at the hos-
pital level by the anesthesiologist in charge and
by the surgeon in charge. Ideally, each com-
munity should set up an anesthesia mortality
committee which would review these deaths on
an anonymous but compulsory basis. In this
way, we could learn to prevent needless death.

Some common denominators in 1,200 cases of cardiac arrest.
Ann. Surg. 137:731, 1953.

4. Berne, C. J., Denson, J. S., and Mikkelsen, W. P.: Car-

diac arrest — problems in its control. Am. J. Surg. 90:189,

1955.

5. Eckenhoff, J. E.: Some preoperative warnings of potential

operating-room deaths. New England J. Med. 255:1075,

1956.

Skin grafting procedures can he improved by deferring application of the
graft until a satisfactory bed is prepared, bv early inspection of the graft, and
by use of wet dressings.

Although a fresh surgical wound is the best base for application of a graft,
uncontrollable capillarv bleeding after the excision of giant nevi, old fibrotic
ulcers, burn scars, or large hemangiomas may cause hematoma. Covering the
area with sterile pressure dressings for one or two days, during which time anti-
biotics are given, will create a dry bed. Grafting should be delaved for at
least one day after radical mastectomy. If immediate grafting is done, the
transplanted skin is sutured to the underlying tissue but not to the adjacent
skin flaps, thus preventing the pooling of blood beneath the graft. After op-
eration for parotid tumors or lymphangiomas, two davs or more of salivary or
lymphatic drainage are also advisable before grafting. After excision of radia-
tion lesions and extensively fibrotic areas, longer delay and dailv application
of dressings with a coarse mesh gauze base are desirable to foster granulation.

Earlv inspection of the graft is advisable if complications are suspected.
Drainage of underlying blood, serum, or pus and application of pressure will
often save the graft. Sometimes, sutures must be removed from one edge of
a graft to evacuate a large organized hematoma. Earlv examination will not
dislodge the transplanted skin if ultrafine mesh nylon silk is applied over the
grafted area.

When the viability of a graft is in doubt after the first dressing, wet boric
acid applications for twenty-four hours are often beneficial. This procedure is
not advisable for infants or children with large areas of denuded flesh because
of possible toxic absorption.

Paul W. Greeley, M.D., and John W. Cuhtin, M.D., University of Illinois and St. Luke's and
West Side Veterans Administration hospitals, Chicago. Plast. & Reconstruct. Surg. 19:420-423, 1957.

68

THE JOURNAL-LANCET

Memngococcic Meningitis and
Meningococcemia with Probable
Waterhouse-Friderichsen Syndrome

KENNETH F. SWAIMAN, M.D., and
RICHARD B. RAILE, M.D.

Minneapolis, Minnesota

CASE REPORT

A 13-year-old white boy was first seen at Minneapo-
lis General Hospital on August 4, 1957, with the
chief complaint of vomiting and headache. Two days
prior to admission, he became anorexic and a severe
frontal headache developed. The following morning he
awoke complaining of chills and spent almost the entire
day before admission in bed. His temperature was not
taken, but the chills persisted and he became increas-
ingly anorexic. The night prior to admission he slept
well but awakened confused and lethargic. His mother
noted a rash over his entire body so she took him to the
receiving room of a private hospital where he was re-
ferred immediately to Minneapolis General Hospital. His
past medical history was noncontributory to the present
illness. As far as could be ascertained, he had not been
in contact with any contagious disease. He had mani-
fested no upper respiratory symptomatology.

Initial examination revealed a well-nourished, well-
developed white male who was lethargic and confused.
He responded to simple commands and was able to rec-
ognize his mother. His temperature was 103.4 reetally,
blood pressure was 140/70, respirations were 22, and
weight was 51 kg. He had a rash over his entire body—
a dark, erythematous, blotchy eruption which blanched
on pressure. Few frankly purpuric lesions or petechiae
were noted. There was no evidence of trauma about the
head. The tympanic membranes were slightly dulled,
but there was no definite injection. The pharynx was
slightly injected. There were numerous enlarged bilateral
anterior cervical nodes. The lungs were clear to percus-
sion and auscultation. Examination of the heart revealed
a normal sinus rhythm, no murmurs, and no apparent
enlargement. The abdomen was soft and no abnormali-
ties were noted. Neurologic examination revealed a posi-
tive Brudzinski sign and a suggestive positive Kernig’s
sign. All the cranial nerves appeared intact. The gag re-
flex was present. The fundi did not appear abnormal.
The deep tendon reflexes were all present and equal.
They appeared to be of normal magnitude. Toe signs
were negative.

Between the time of admission and the time of com-
pletion of physical examination (about forty minutes),
the patient became much more restless and incoherent,
and stiffness in his neck and back increased markedly.

kenneth f. swaiman and richard b. raile are asso-
ciated with the Department of Pediatrics of Minne-
apolis General Hospital and the Department of Pe-
diatrics of the University of Minnesota.

A lumbar puncture was performed. The fluid obtained
was grossly cloudy and the opening pressure was in ex-
cess of 600 mm. of water. Examination of the fluid
revealed 6,040 white blood cells, 100 per cent of which
were polymorphonuclears. The smear showed numerous
gram-negative diplococci. Spinal fluid sugar was 28-
mg. per cent and the protein was 408-mg. per cent. The
hemogram revealed a hemoglobin of 14.7-gm. per cent,
white blood cells 25,000 with 93 per cent polvmorpho-
nuclears, 5 per cent lymphocytes, and 2 per cent mono-
cytes. Urinalysis was essentially normal. Admission
blood sugar was 1 19-mg. per cent, CO; combining power
was 23 mEq. per liter, and serum chloride was 99 mEq.
per liter. After completion of the spinal tap and prior
to the return of laboratory reports, the patient was begun
on a regimen which included intravenous fluids; sodium
sulfadiazine 200 mg. per kilogram per twenty-four hours,
Vi subcutaneously and 'A intravenously initially and then
subcutaneously only; and chloramphenicol 100 mg. per
kilogram per twenty-four hours.

Within one and one-half hours after admission the
patient’s blood pressure dropped abruptly to 100/55.
His skin became cool, and an alarming pallor developed.
His level of consciousness became more depressed. Hy-
drocortisone sodium succinate 150 mg. was given intra-
venously. Within an hour, his blood pressure was 120/75.
His skin became warm, and the color improved signifi-
cantly. Curiously, the previously described eruption had
disappeared. Upon report of the spinal fluid smear, the
patient’s treatment was altered to include aqueous crys-
talline penicillin, and the chloramphenicol therapy was
discontinued. Throughout the day, he remained restless
and semicomatose. His blood pressure stabilized at
120/70, and the eruption, which had disappeared, re-
appeared in the afternoon and remained for two to
three hours before vanishing permanently. He was given
an additional 25 mg. of cortisone intramuscularly later
that day. By evening, he was able to take fluids orally.
Twenty-four hours after admission, his rectal tempera-
ture was normal and, although moderately disoriented
and at times hallucinating, he was still able to take fluids
orallv without difficulty. Except for a transient episode
of gross hematuria, his subsequent course was most sat-
isfactory and uneventful. Penicillin and oral sulfonamide
therapy was continued for one week. On the second and
third days after admission, he was given 25 mg. of cor-
tisone every six hours. Subsequently, this dose was grad-
ually tapered over a ten-day period and discontinued.

Blood cultures taken on admission revealed numerous
colonies of gram-negative diplococci, which were charac-
teristic of Neisseria meningitidis. We feel that this was

FEBRUARY 1958

69

a case of meningococcic meningitis as well as meningo-
coccemia with probable early Waterhouse-Friderichsen
syndrome.

DISCUSSION

History. As late as 1938, it was candidly stated
that meningococcemia with the Waterhouse-
Friderichsen syndrome was 100 per cent fatal
and usually so within twenty-four hours.1 In
1940, with use of the sulfonamides,2 adrenal cor-
tical extract, and antimeningococcic serum, the
first cure of this syndrome was reported. During
the next 10 years, numerous attempts at therapy
incorporating use of adrenal cortical extract and,
later, desoxycorticosterone with sulfonamide and
penicillin were reported.3-6 Objective study of
the results of this type of steroid therapy left a
great deal of doubt as to the value of the steroids
in therapy of the Waterhouse-Friderichsen syn-
drome. In June 1950, a patient who had prev-
iously been given penicillin, sulfonamides, and
adrenal cortical extract and who appeared defi-
nitely moribund was given cortisone. He abrup-
tly improved and lived.7 This was the first re-
ported use of cortisone in the treatment of this
syndrome. Within six months, at least 2 other
cases8,9 were reported in the literature with en-
couraging results. Since that time, numerous
case reports10-13 have established that the use of
cortisone, hydrocortisone, and some of the newer
“meta” steroids are important additions to the
therapy of the Waterhouse-Friderichsen syn-
drome. In the case presented, intravenous rapid
acting hydrocortisone sodium succinate was used
initially with prompt and striking effect.

PATHOLOGY

It was thought for many years that gross, frank,
bilateral, adrenal hemorrhage causing acute adre-

REFERENCES

1. Christian, II. A.: The Waterhouse-Friderichsen Syndrome:

Fulminating Septicemia, Usually Meningococcic, with Ad-
cemia (Waterhouse-Friderichsen syndrome) with recovery:
(Supp.). New York: Oxford University Press, 1946, Vol. 5,

pt. 1, p. 106.

2. Carey, T. N.: Adrenal hemorrhage with purpura and septi-

cemia (Waterhouse Friderichsen syndrome) with recovery:
case report. Ann. Int. Med. 13:1740, 1940.

3. Appei.baum, E., and Nelson, J.: Sulfadiazine and its sodium
compound in treatment of meningococcic meningitis and men-
ingococcemia. Am. J. M. Sc. 207:492, 1944.

4. Bush, F. W., and Bailey, F. R.: Treatment of meningococcic
infections with especial reference to Waterhouse-Friderichsen
syndrome. Ann. Int. Med. 20:619, 1944.

5. Lohrey, R. C., and Toomey, J. A.: Epidemic meningitis and
meningococcemia treated with penicillin. J. Pediat. 28:86,
1946.

6. Sweet, L. K., Dowling, H. F., and Howell, M. J.: Acute
meningococcemia. J. Pediat. 30:438, 1947.

7. Nelson, J., and Goldstein, N.: Nature of Waterhouse-

Friderichsen syndrome. J.A.M.A. 146:1193, 1951.

8. Nelson, J., and Goldstein, N.: Nature of Waterhouse-

Friderichsen syndrome, (addend.). J.A.M.A. 146:1229, 1951.

9. Newman, L. R.: Waterhouse-Friderichsen syndrome; report

of a cure effected with cortisone. J.A.M.A. 146:1229, 1951.

10. Hodes, H. L., Moloshok, R. E., and Markowitz, M.: Ful-
minating meningococcemia treated with cortisone; use of
hlood eosinophil count as a guide to prognosis and treatment.

nal insufficiency was the etiology of the Water-
house-Friderichsen syndrome. This theory was
based on vascular damage secondary to a ful-
minating septicemia. In the early 1940’s, several
papers revealed numerous cases of the clinical,
classical Waterhouse-Friderichsen syndrome
which did not have the expected bilateral adre-
nal hemorrhages.1415 However, careful patho-
logic studies revealed that the hemorrhages mer-
ely represented the extreme late stages of adrenal
destruction, and, thus, when hemorrhage was
present, the primary pathologic picture was ob-
scured. These studies revealed that there was
degeneration of the cell cords of the zona fasci-
culata and neighboring adrenal cortical cells.16
When parenchymal destruction had taken place,
the highly vascular adrenal gland was engulfed
by hemorrhage as the perivascular structures
were destroyed. Experimental work has demon-
strated that this picture is not incompatible with
extreme stress, such as would be experienced
during fulminating septicemia.1718 Similar adre-
nal changes have been produced experimentally
as a “side reaction in studies of the localized
Shwartzman phenomenon.19 Microscopic studies
of the skin lesions have shown that they are
secondary to vascular dilatation and capillary
damage.

SUMMARY

A 13-year-old bov with meningococcic menin-
gitis and meningococcic septicemia with prob-
able early Waterhouse-Friderichsen syndrome
was successfully treated by use of hydrocorti-
sone, sulfonamides, and penicillin. The evolution
of the present therapeutic program is discussed
as well as some phvsiopathologic concepts of
this disease.

Pediatrics 10:138, 1952.

11. Breen, G. E., Emond, R. T. D., and Walley, R. V.: Wa-
terhouse-Friderichsen syndrome treated with cortisone; report
of 2 cases. Lancet 1:1140, 1952.

12. Griffin, J. W., Daeschner, C. W.: Meningococcal infec-

tions; with particular reference to fulminating meningococ-
cemia treated with cortisone and norepinephrine. J. Pediat.
45:264, 1954.

13. Baumann, F., Pearson, D. E., and Levin, M.: Adrenal cor-
tical steroids in management of a case of meningococcemia.
J. Pediat. 43:575, 1953.

14. Williams, 11. : Meningococcal infections in infancy and

childhood: II. Meningococcal septicemia with special reference
to adrenal apoplexy or the Waterhouse-Friderichsen syndrome.
M. J. Australia 2:557, 1942.

15. Schwarz, J.: Adrenal hemorrhages in meningococcal sepsis.

Arch. Path. 41:503, 1946.

16. Rich, A. R.: A peculiar type of adrenal cortical damage asso-
ciated with acute infections, and its possible relation to cir-
culatory collapse. Bull. Johns Hopkins Hosp. 74:1, 1944.

17. Zamcheck, N.: The normal human adrenal cortex and its

response to acute diseases. Am. J. Path. 23:877, 1947.

18. Selye, H., and Stone, H.: On the Experimental Morphology
of the Adrenal Cortex. Springfield, Illinois: Charles C Thomas.
1950.

19. Black-Schaffer, B., Hiehert, T. G., and Kerry, G. P.:
Experimental study of purpuric meningococcemia in relation
to Shwartzman phenomenon. Arch. Path. 43:28, 1947.

70

THE JOURNAL-LANCET

Will E. Donahoe, M.D.

Phys man , Educator, mid Humanitarian

By j. ARTHUR MYERS, M.D.

Fok more than a third of a century, no meeting
of pediatrists or public health workers, either
local or national, has been complete without Will
Donahoe’s presence. It has not been just from his
participation in formal programs but from personal
conversations with him in hotel rooms and lobbies,
in assembly halls immediately before and after meet-
ings, during breaks to visit exhibits, and so forth,
that so many physicians have learned so much from
him.

Aside from periods of schooling at St. Thomas
College, St. Paul, and the University of Illinois, his
entire life has been lived in Sioux Falls, South Da-
kota, where he was born May 18, 1886, when that
area was still Dakota Territory. After completing
an internship, he entered general practice in Sioux
Falls in 1913. There he saw the almost unlimited
possibilities of increasing human longevity through
treatment and prevention of diseases which were
incapacitating, maiming, and crippling large num-
bers of children. He also saw the opportunity afford-
ed him of informing parents and the public in gen-
eral of methods bv which children could be pro-
tected against many of the conditions that were de-
stroying them. Therefore, he decided to devote the
remainder of his professional life to that cause. In
1919, he went to the University of Iowa for post-
graduate work in pediatrics. He then spent five
months divided between clinics and ward rounds
under Doctors Abt and Brenneman in Chicago and
Doctor Sedgewick of the University of Minnesota,
before returning to Sioux Falls where he has since
confined his practice to pediatrics and public health.

Much of the time that could be snatched from the
demands made upon him in practice was devoted
to reading the best medical journals and books in
his field. This, together with attendance at conven-
tions, kept him abreast of the latest developments
and far ahead of most physicians.

He realized that the best time to transmit infor-
mation concerning health was when persons were
personally interested. Therefore, he has devoted a
great deal of time to individual patients and their
families, which inspired their confidence in him.

He has always enjoyed community endearment
as he was ever ready to devote whatever time and
energy any community health problem required. F’or
example, in 1920, he introduced into the area he
served the first immunization program against diph-
theria. The same year he established the first public
clinic in the state for ill and well children and served
as school physician from 1920 to 1936— for 11 years
without compensation.

Beginning in 1925 and continuing until 1936, he
was the health officer of Sioux Falls on a part-time
basis. Since this office was the official health agency,
a magnificent opportunity was provided to make
recommendations, to introduce new procedures, and
to support others already being utilized. In fact,
during this period. Doctor Donahoe contributed sig-
nificantly to the entire state program, not only
among physicians but also with other groups, includ-
ing educators and the public. Better sanitation laws
were enacted pertaining to such items as dairy prod-
ucts. He supported the veterinarians in their cam-
paign to eradicate tuberculosis from the cattle herds.

FEBRUARY 1958

71

He instituted tuberculin testing of school children.

As he retired from the health officership of Sioux
Falls, he became superintendent of the Board of
Health of his entire (Minnehaha) county. He per-
sonally checked for three successive years the 100
rural schools of the county. This had never been
done, and the sanitary conditions and physical facili-
ties were most deplorable. More than 60 per cent
of the drinking water was proved unsafe. Correc-
tions were obtained during this period in practically
every instance. During these three years, the chil-
dren were tuberculin tested and examined and re-
ferred to their own physicians for immunizations and
corrections. The promised payment by the county
commissioners was denied and the services, there-
fore, were discontinued. Recent survey of the schools
by the press showed that they had again dropped
to their former state.

He led the way in the organization of the South
Dakota State Health Officer’s Association. While
president of this organization, he combined it with
the Tuberculosis Society under the name South Da-
kota Health and Tuberculosis Association.

He formulated the idea of greater political and
economic strength in a union of the inter-allied
groups in South Dakota in 1933. This brought all
6 groups together in Sioux Falls in 1936 for their
annual meetings and general sessions. Some 1,100
persons attended the closing banquet. This was the
first group of so manv inter-allied bodies in the coun-
try. Communications were received from the New
York Society, and official representations attended
from Illinois and Iowa State Medical Associations.

He has been a prominent worker with the Red
Cross and the Salvation Army, having served on
their boards. At present, he is a member of the
Executive Board of the Volunteers of America.

The vear after he entered general practice, he
organized the first Boy Scout troup in Sioux Falls.
His interest in this organization has continued
throughout the years and, in 1938, he received the
Silver Beaver award of the Bov Scouts of America.

During World War I, he served in the United
States Medical Corps and was Commander of the
United States Public Health Service of Armed Forces
Reserve from 1944 to 1954. He is a charter mem-
ber of the American Legion.

Doctor Donahoe is a member of the Sioux Falls
Chamber of Commerce, Rotary, Elks, Walton
League, and the Minnehaha Country Club. He is
past State Master of the Fourth Degree Knights of
Columbus.

His popularity among physicians is evidenced by
his election to three successive terms as president of
the Seventh District Medical Society in 1928, 1929,
and 1930. He served on the council of the State
Medical Association from 1930 until he retired as
chairman in 1945.

He has long been a member of the active staff of
the Sioux Valley and McLennan hospitals, as well as
attending physician to the South Dakota State Chil-
dren’s Home, Presentation Home, and Lutheran
Home House of Mercy. He organized the Guild of
Catholic physicians and has since been its president.

Nationally and internationally he is a fellow of
the American Medical Association, a diplomate of
the American Board of Pediatrics, a fellow in the
Academy of Pediatrics, a fellow in the Academy of
Internal Medicine, as well as past fellow of the
American Association of School Physicians and the
American Public Health Association.

He has long been active in the Northwestern Pe-
diatric Society and the Sioux Valley Medical Society,
which he has served as president.

He is co-chairman of the Inter-Hospital Commit-
tee in Sioux Falls, Community Physicians Disaster
Committee, and chairman of the American Academy
of Pediatrics.

It is difficult to comprehend how one physician
could in a lifetime serve so many so well and in
so many ways. In leading and directing these activ-
ities, Doctor Donahoe has exhibited unusual ability
in avoiding jealousy and enmity, which so long ago
caused it truly to be said that “The prophet is not
without honor save in his own country.” In 1952,
the Cosmopolitan and Civic Clubs of Sioux Falls
conferred upon him the Distinguished Community
Service Award based on the theme of charity and
children.

In 1957, the South Dakota State Medical Associa-
tion conferred upon him its Distinguished Service
Award for practice of medicine and promotion of
public health.0

In addition to the large volume of informal teach-
ing done throughout his professional career of 47
years, he is also clinical professor of pediatrics at
the Medical School of the University of South Da-
kota.

This sketch, which should be expanded to a large
volume, must not close without an expression of
personal appreciation. Over a long period of years,
he has been a true friend. Our meetings at vari-
ous national conventions, as well as in South Dakota
and Minnesota have, without exception, been most
helpful and inspiring. His kindly spirit, his calm
and considered judgment, lack of selfishness, his
great store of knowledge, his numerous accomplish-
ments, and his goodness in every way have made
each of our many associations most pleasant and
profitable. His life is one to be emulated by all who
strive to become truly great American citizens.

“This citation was published in full in the July issue of
the South Dakota Journal of Medicine and Pharmacy.
With consent of the editor, I have drawn freely from
this citation. The South Dakota State Medical Associa-
tion kindly provided the photograph.

72

THE JOURNAL-LANCET

IPRONIAZID

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Original Research in
Medicine and Chemistry

21A

Progress in Radiobiology. Proceed-
ings of the fourth international
Conference on Radiobiology held
in Cambridge, August 14 to 17,
1955. Edited by Joseph S. Mit-
chell, Barbara E. Holmes, and
Cyril L. Smith, 1956. Spring-
field, Illinois: Charles C Thomas,
557 pages. $12.75.

A great variety of research topics
and interesting discussions by dele-
gates are presented in this book.
These factors, together with the
available bibliographies, provide the
reader with an excellent reference
work in radiobiology. This account
is of particular value to the investi-
gator working in America because of
the wealth of information coming
from research laboratories in other
countries.

This account of current trends in
radiobiologic research emphasizes
the importance of fundamental re-
search on the effects of ionizing ra-
diations on biologic systems as a
basis for improved clinical applica-
tions. Furthermore, it serves to point
out the need for investigators trained
in various disciplines in order to
carry out an effective research pro-
gram encompassing the many facets
of radiobiology.

M. K. Loken, Ph.D.

•

The Merck Manual of Diagnosis
and Therapy , ed. 9. Editorial
board: Charles E. Lyght, M.D.,
editor; William P. Boger, M.D.;
George A. Carden, M.D.; Augus-
tus Gibson, M.D.; and Dickin-
son W. Richards, M.D., 1957.
Railway, New Jersey: Merck &
Co., Inc., 1,870 pages, illustrated.
Cloth $6.75, deluxe $9.00.

This popular and comprehensive
book has been thoroughly revised,
and many portions have been com-
pletely rewritten. Additional excel-
lent and extremely useful plates
have been included, which, for ex-
ample, illustrate the technic of intra-
articular injection, tracheotomy, lum-
bar puncture, and gastrointestinal
suction siphonage procedures. Con-
tributing to its value are hundreds
of prescriptions, 63 tables, and spe-
cial sections devoted to the enhance-
ment of medical diagnosis and treat-
ment. The index has been consid-
erably expanded and more liberally
cross-referenced than before.

Although this edition contains
over 300 pages more than the last,
the use of extra thin paper has pre-
served the handy format of the
book.

The Merck Manual continues to

BOOK

RFVTFWS

.A A T .iBki. mW «4 f "

be an outstandingly accurate and
up-to-date reference book, giving
practical assistance to all those en-
gaged in the practice of medicine
and in the allied professions.

J. A. Myers, M.D.

•

Physio pathology of the Reticulo-
endothelial System, edited under
direction of B. N. Halpern, 1957.
Springfield, Illinois: Charles C

Thomas. $9.00.

Seventeen authoritative articles on
the reticulo-endothelial system and/
or related problems constitute the
contents of this volume, which sum-
marizes the proceedings of a sym-
posium organized bv the Council
for International Organizations of
Medical Sciences and the Unitarian
Service Committee under the able
direction of B. N. Halpern of Paris.

It is well over four decades ago
since Aschoff crystallized the con-
cept of the RES on the basis of
studies with colloidal suspensions of
vital dyes. Since his pioneering
work, the readily identifiable prop-
erty of phagocytosis is known to be
related to the cells derived from the
diffuse reticulum and the lining vas-
cular epithelium of connective tis-
sues (the RES). These phagocytic
cells are now regarded as a third
systemic line of defense, which
comes into play over and above the
first two defenses, namely, those at
the site of entry of an invader and
those at the site of the regional
lymph nodes. In addition to phago-
cytic functions, certain metabolic and
humoral defense functions are also
related to the RES. These cells are
able to absorb ehylomicra formed
by lipids and exogenous cholesterol
and participate in iron metabolism
by storing it or by controlling its
exchanges with humoral factors of
iron transport. The more important
known roles of the RES concern,
however, the handling of toxins and
particularly endotoxins, but opinions
are still divided on the exact mech-
anisms and role of this defense func-
tion of the RES. The title of the
book is, perhaps, misleading; patho-

physiologic aspects of the RES rath- U
er than physiopathologic considera- j
tions are in the foreground. This 1
may be more than only a matter of ,
semantics, since it is the physiology
of the RES which will call for con- j
siderable additional work in the fu-
ture. The status quo of our knowl-
edge in this field is hardly surpris- J
ing. The RES originated as a con-
cept primarily from morphologic
considerations. It has gained in- |
creasing importance from contribu- i
tions in many other fields ranging
from physical chemistry to bacteri-
ology and immunology. The meth-
odology available for physiologic il
studies on the RES is discussed in i
detail in this volume, which is rec-
ommended primarily to investigators I
in the basic and applied medical
sciences.

Franz Halberg, M.D. i

*

Lupus Nephritis, by Robert C.
Muehrcke, Robert M. Kark,
Conrad L. Pirani, and Victor
E. Pollack, 1957. Baltimore:
Williams & Wilkins Co., 133'
pages, 13 pages of references, 11
chapters. $3.00.

This book is a classical, detailed, '
clinical, and pathologic studv of
lupus nephritis based on renal bi-
opsies. The authors’ experiences with
33 patients provide the background.
The diagnosis, prognosis, and treat- '
ment are vividly discussed. The il-
lustrations of the histologic changes
are excellent. The literature is ex-
tensively reviewed. The text is very
well written, and there is a mini-
mum of typographical errors. The
bibliography is comprehensive. The
paper is of excellent quality. This
text would be a valuable addition
to the library of any physician.

M. P. Reiser, M.D.
o

The Recurrent Laryngeal Nerves in
Thyroid Surgery, by William H.
Rustad, M.D., 1956. Springfield,
Illinois: Charles C Thomas. $4.50.

This is an excellent anatomic study
of the recurrent laryngeal nerves,
which presents a practical applica-
tion to the thyroid surgeon. The
author’s purpose is to call attention
to the recent recognition that many
of the postoperative derangements
of laryngeal function are due to
damage of the branches of the re-
current laryngeal nerve, hitherto
generally regarded as a single nerve.

The anatomy of the larynx is ac
curately reviewed because the right
and left recurrent laryngeal nerve
(Continued on page 24A)i

ht

22A

When

a A

the bronchial tree
has too much “bark”

make cough MORE PRODUCTIVE,
LESS DESTRUCTIVE

‘‘Significantly superior”2 cough therapy for ‘‘markedly”
reducing the severity and frequency of coughing,1 for
increasing respiratory tract fluid,1 for making sputum
easier to raise,3 and for relieving respiratory discomfort.4

A. H. ROBINS CO., INC., RICHMOND 20, VIRGINIA

Ethical Pharmaceuticals of Merit since 1878

References:

1. Blanchard, K., and Ford, R. A.:
Clin. Med. 3:961, 1956. 2. Cass, L. J.,
and Frederik, W. S.: 2:844, 1951.
3. Hayes, R. W., and Jacobs, L. S.:
Dis. Chest 30:441, 1956. 4. Schwartz,
E., Levin, L., Leibowitz, H., and
McGinn, J. P.: Am. Pract. & Digest
Treat. 7:585, 1956.

ROBITUSSIN

Glyceryl guaiacolate 100 mg. and desoxyephedrine hydrochloride 1 mg. per 5 cc.

ROBITUSSIN’ A-C

Robitussm with Antihistamine and Codeine: Same formula as Robitussin, plus
prophenpyridamine maleate 7.5 mg. and codeine phosphate 10 mg. per 5 cc. (Exempt narcotic)

V s' '

BOOK REVIEWS

(Continued from page 22A)
supplies all the muscles of the lar-
ynx except the cricothyroid. The
cricothyroid muscle receives its in-
nervation from the external branch
of the superior laryngeal nerve. The
author’s investigations have estab-
lished that the recurrent laryngeal
nerve frequently divides into two
branches, less often into four to six
branches, all entering the larynx.

In making a clinical application of
these facts, the author states that
“the recurrent laryngeal nerve,
whether as a main single trunk or
whether broken up into a variable
number of component branches, has
been seen to enter into many di-
verse and completely unpredictable
branching patterns.” He further
states that there are no constant dif-
ferences in the relationship between
the inferior thyroid artery and the
recurrent nerve on the right and left
side. The author from his study,
embryologically states emphatically
that it is impossible for the recur-
rent laryngeal nerve to enter the
thyroid gland parenchyma. He fur-
ther concludes that “because of the
branching of the nerve, it is not
practical, where the primary mission
of the operation is to remove the
gland, to isolate the recurrent nerve
completely, since the operator may

be deceived by dissecting out only
one branch.” In a further clinical
suggestion, he recommends the ap-
plication of ligatures to the inferior
thyroid artery lateral to the tracheo-
esophageal groove to avoid injury to
the nerve. Pre- and postoperative
laryngoscopy are urged. Numerous
excellent illustrations of the anatomy
of the recurrent laryngeal nerves are
presented.

This book should be in the pos-
session of every surgeon engaged in
thyroid surgery.

Martin Nordlano, M.D.

•

Hypertension, by Irvine H. Page,

M.D., ed. 2, 1956. Springfield, Il-
linois: Charles C Thomas. $3.00.
This manual on hypertension, writ-
ten for patients, for them amounts to
a textbook of sound information. An
outstanding student of and authority
on hypertension discusses the subject
and explains what it is, why the phy-
sician has performed the various ex-
aminations, and what can be done
about the condition. While the best
transfer of information to the patient
is given by the physician who has
personally examined him at not in-
frequent intervals, the patient’s ac-
cess to such a book will supplement
his physician’s viewpoint. This man-
ual may well indeed be recommend-

ed for the inquisitive and curious
person. The paragraphs on Cultiva-
tion of the Soul may profitably be
read by physician and patient alike.

C. A. McKinlay, M.D.

•

Natural Childbirth, by H. B. Atlee,
M.D., 1956. Springfield, Illinois:
Charles C Thomas, 79 paces.
$2.75.

This is a small volume as are the
others of the American Lecture se-
ries. The author presents his own
concepts of a philosophic approach
to pregnancy and, particularly, to
labor. He describes his own technic
for natural childbirth together with
the organization of the prenatal
teaching classes and their content.
There is a chapter dealing with the
physical arrangement of a lying-in
unit for use in this sort of an ap-
proach to labor.

It is a short presentation but con-
tains a great deal of what appeals to
the reviewer as the wisdom of care-
ful observation and long experience.
Some of his conclusions are stated
in pungent terms which will remain
in the mind of the reader. One could
hope that everyone doing obstetrics
would read the essay and ponder
over it.

John L. McKelvey, M.D.

News Briefs . . .

North Dakota

The new clinic at Northwood, North Dakota, is now
completed. An addition to the Northwood Deaconess
Hospital, the building is of modern design and well
equipped to meet a wide range of medical and surgical
needs.

e ooo

Dr. L. G. Pray of Fargo has been elected president of
the First District Medical Society. Other officers are:
Dr. A. L. Klein, Fargo, vice president; and Dr. Frank
M. Melton, Fargo, secretary-treasurer. Delegates to the
North Dakota State Medical Society are: Dr. Arthur C.
Burt, Dr. Frank M. Melton, Dr. W. L. Macaulay, Dr.
F. A. DeCesare, Dr. John S. Gillam, all of Fargo; and
Dr. E. ]. Beithon, Wahpeton. Alternates are: Dr. D. G.
Jaehning, Wahpeton; Dr. L. E. Wold, Dr. |. F. Hough-
ton, Dr. J. F. Schneider, Dr. B. F. Amidon, and Dr.
Henry A. Norum, all of Fargo. Dr. Earl M. Haugrud,
Fargo, was elected censor.

O O O O

Dr. Phillip O. Dahl has been elected president of the
medical staff at St. Alexius Hospital in Bismarck. He
succeeds Dr. P. Roy Gregware, who will continue to
serve on the executive committee of the staff in his
capacity as past president. Other officers elected to serve

during 1958 include: Dr. Paul L. Johnson, president-
elect; Dr. Olav V. Lindelow, secretary; and Dr. Robert
W. Henderson, member-at-large.

o o o o

Dr. Ralph D. Weible, who has been with the Dakota
Clinic in Fargo since 1940, except for four years with
the Army Medical Corps during World War II, has been
elected president of the St. John’s Hospital staff. Other
new officers are: Dr. Lee A. Christoferson, vice presi-
dent, and Dr. Richard |. Zauner, secretary-treasurer. New
members of the advisory board are Dr. Zauner and Dr.
|. F. Schneider. Holdover members are Dr. W. B. Arm-
strong and Dr. O. A. Sedlak.

o o o o

Dr. Clarence Davis, Jr., a Watford City physician, has
been appointed district deputy health officer for Mc-
Kenzie Countv.

o o o o

Dr. Robert Ivers, who recently completed his intern-
ship and residency at St. Luke’s Hospital, Fargo, has
been granted a fellowship in neurology at the Mayo
Clinic. Dr. Ivers left for Rochester on December 27.

o o o o

Dr. Gilbert J. Guscott and Dr. John L. Magness,
both natives of Ohio, have become associated with the
Dakota Clinic in Fargo. Dr. Guscott is head of the De-
partment of Physical Therapy, and Dr. Magness is in
the Department of Internal Medicine.

(Continued on page 26A)

24A

SERVING THE MEDICAL PROFESSION OF MINNESOTA,
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

Surgery in Heart Disease

JOHN FRANCIS BRIGGS, M.D.
St. Paul, Minnesota

Surgeons have become important members of
the team in the diagnosis and treatment of
heart disease. As a result of their efforts, great
contributions to cardiology have been made and
many new treatments have been devised, which
augment the medical care of the patient suffer-
ing from heart disease. Some surgical procedures
are curative and others palliative. The following
cardiovascular diseases may be benefited by sur-
gery:

the aorta

Patent ductus arteriosus is essentially an arterio-
venous fistula. A machinery-hum murmur heard
over the pulmonary artery area to the left of the
sternum establishes the diagnosis. In addition,
there is a wide pulse pressure and usually a
characteristic x-ray picture. The electrocardio-
gram is of no value in a patent ductus arteriosus.
Treatment is surgical.

The “ aorticopulmonanj window” syndrome.
The physical findings are the same as those in
a patent ductus, but the machinery-hum murmur
may be heard only at the lower end of the ster-
num. Many times the diagnosis is not estab-
lished until surgical exploration is carried out.
The surgeon attempts to find a patent ductus and,
not finding it, discovers the communication be-
tween the aorta and the pulmonary artery. An-

john f. briggs is associate professor of clinical medi-
I cine at the University of Minnesota.

Paper presented before the North Dakota State
Medical Association at Fargo, North Dakota, May
27, 1957.

giograms may be of value in the diagnosis. Sur-
gerv, when possible, is curative.

Coarctation of the aorta is diagnosed by find-
ing hypertension in the upper extremity and hy-
potension in the lower extremity. The physical
findings are negligible, but a systolic murmur
may be heard over the aortic area, and, when
the lesion is associated with a bicuspid aortic
valve, a diastolic murmur may also be present.
The diagnosis can be made clinically by feeling
the radial artery while, at the same time, palpat-
ing the femoral artery. In coarctation of the
aorta, the femoral pulsations are diminished or
absent. The x-ray film is often of no value, but
scalloping of the ribs may be present. The elec-
trocardiogram may be normal or show a left-
axis deviation. Angiograms may indicate the
degree of stricture as well as the location of
the stricture in the aorta. Surgery is curative.

Arteriovenous fistulae, both congenital and ac-
quired, can be cured by surgery. Thrombosis of
the aorta is amenable to surgery as are arterial
embolic phenomena.

Abnormalities of the vascular rings may pro-
duce either dysphasia or stridulous respiration.
The diagnosis should be suspected in any new-
born who has difficulty in swallowing or who
has a stridulous type of respiration. Once the
diagnosis is established, the treatment consists
of ligation and severance of the offending blood
vessel.

Aneurysms of the aorta may be congenital or
acquired. Previously, almost all acquired aneu-
rysms were luetic in origin, but todav they rep-
resent an arteriosclerotic process. The diagnosis

may he made accidentally by finding the pulsat-
ing mass on physical examination or by seeing
a mass on the x-ray film or by fluoroscopy. Occa-
sionally, the first knowledge of the existence of
the aneurysm occurs as the result of a vascular
crisis after rupture or dissection of the aneurysm.
The shock picture, drop in blood pressure, and
the altered pulsation of the affected blood vessels
make the diagnosis easy. Operation is indicated
as an emergency procedure. It is my opinion
that all patients with aneurysm of the aorta
should undergo surgical treatment if feasible.

HEART

In a review of the lesions that may be amenable
to surgical treatment, we shall start with those
that are within the heart itself.

Septal defects. Atrial septal defects are not
uncommon. The diagnosis may be suspected
because of the gracile habitus of the patient.
Cyanosis and/or clubbing may or may not be
present. There is usually a systolic murmur over
the base of the heart, and there may be an asso-
ciated diastolic murmur. Tbe roentgenogram is
rather characteristic in that it shows an enlarge-
ment in the conus area with dancing pulmonary
blood vessels on fluoroscopy. The electrocardio-
gram may be normal or reveal a right-axis devia-
tion. Cardiac catheterization as well as angio-
cardiography are of value in the diagnosis and
management of these patients. I believe that
surgery is indicated in all of these cases.

Ventricular septal defects may vary in size
from minute openings to complete absence of
the ventricular wall. The physical findings reveal
a loud blowing systolic murmur over the middle
of the sternum opposite the third and fourth
interspaces. In addition, a systolic thrill is found.
The heart may be normal in size. Roentgeno-
grams are of no importance in diagnosis, and the
electrocardiogram is seldom an aid in this re-
spect. Cardiac catheterization and angiocardiog-
raphy, as well as other laboratory procedures, are
of great value in both the diagnosis and in plan-
ning treatment. I believe that these patients do
not require surgical treatment unless there is
evidence of cardiac embarrassment.

A septal defect can occur by a perforation of
the septum complicating acute myocardial in-
farction. The symptoms are sudden, severe heart
failure complicating the course of the myocardial
infarction. The signs are the same as in the con-
genital defect. Surgery should be attempted.

Tetralogy of Fallot. In this condition, there is
pulmonary stenosis with an interventricular sep-
tal defect, various degrees of transposition of the
great vessels, and enlargement of the right side

of the heart. These patients are the classical
“blue baby” individuals. Cyanosis is outstanding,
and the fingers and toes are usually clubbed. A
blowing systolic murmur is heard over the pul-
monary area. The roentgenogram shows enlarge-
ment of the right heart, which is verified by the
fluoroscopic examination. The electrocardiogram
reveals a right -axis deviation with or without
strain. In such cases, cardiac catheterization and
angiocardiography may be of great value in as-
sisting in the diagnosis. Surgery is always indi-
cated in these patients.

Anomalous venous return is a condition in
w hich the venous return to the right side of the
heart is abnormal. When recognized, surgery
should be attempted.

Valvular defects — the aortic valve. Aortic
stenosis may be congenital or acquired. If con-
genital, it may be valvular in origin or a sub-
aortic stenosis. In subaortic stenosis, a mem-
brane partially closes off the lumen of the aorta.
Acquired stenosis is almost alwavs rheumatic in
origin, and, in later life, the lesion becomes cal-
cified, producing tbe calcific nodular valve de-
fect. A sytolic murmur is heard over the aortic
area, which is transmitted into the vessels of the
neck and apex. Occasionally, a diastolic murmur
may be present. The blood pressure varies, but
seldom is the diastolic pressure below normal.
A systolic thrill may be present, and the second
sound may be decreased or absent. The roent-
genogram shows enlargement of the left side of
the heart, and calcification may be demonstrated
in the aortic valve. The fluoroscopic examina-
tion adds little to the film studies. The electro-
cardiogram shows left-axis deviation with or
without left heart strain. I feel that the present
treatment of aortic stenosis is such that surgerv
is not indicated unless the patient has ( 1 ) signs
of heart failure, (2) attacks of syncope, or (3)
anginal seizures. The surgical treatment of the
congenital defect, I believe, is indicated.

Aortic insuffciencij . At one time, aortic insuf-
ficiency was almost always luetic in origin, but
today it is almost always rheumatic. The diag-
nosis is made by finding a diastolic murmur in
the aortic area. The diastolic blood pressure
drops, and a wide pulse pressure is present. A-ra\
examination reveals an enlargement of the left
side of the heart. Fluoroscopic examination adds
little. The electrocardiogram reveals left-axis
deviation with or without left heart strain. Sur-
gery in these patients is indicated when there is
(1) congestive heart failure, (2) attacks of syn-
cope, and (3) anginal seizures. The introduc-
tion of a plastic valve decreases the degree of
regurgitation and benefits the patient.

74

THE JOURNAL-LANCET

The pulmonary valve — pulmonary stenosis.
Pulmonary stenosis is essentially a congenital
defect. It may be valvular or infundibular in
type. A blowing systolic murmur is heard over
the pulmonary area, which is frequently associ-
ated with a systolic thrill. The second pulmonic
sound may be diminished or absent. The chest
x-ray reveals an absence or decrease in the size
of the conus area. Fluoroscopic examination re-
veals not only a decrease in this area but a de-
crease in vascularization of the lungs. The elec-
trocardiogram usually shows a right-axis devia-
tion with or without right heart strain. This
defect may be isolated or found in association
with other congenital defects. Cardiac catheter-
ization and angiocardiography are invaluable in
the diagnosis and treatment of this condition.
I believe that all of these patients should under-
go surgery.

Mitral stenosis. Mitral stenosis may be con-
genital in origin, but the greatest number of
cases are due to rheumatic fever. The problem
in diagnosis is to be certain that it is a “tight
mitral stenosis.” I believe that the diagnosis of
a “tight mitral valve” can be made clinically.
The following criteria are necessary to establish
the diagnosis:

1. The presence of either a presystolic or a
mid-diastolic murmur at the apex. A harsh mur-
mur late in systole may also indicate a “tight
mitral valve.”

2. The first sound should be accentuated, the
second pulmonic sound should be duplicated,
and/or a diastolic murmur should be heard over
the pulmonic area.

3. The heart should be normal in size, and
this can be confirmed by fluoroscopic x-ray ex-
amination. In addition, the esophogram should
be positive. The electrocardiogram should re-
veal a right-axis deviation with or without right
heart strain.

Opinion differs as to when surgery is indicated
in the treatment of the mitral valve defect. Ob-
viously, the treatment is directed toward reliev-
ing the pulmonarv hypertension. I feel that sur-
gery is not indicated in mitral stenosis unless
there is (1) clinical evidence of pulmonary hy-
pertension, and/or (2) if medical treatment fails
to control the cardiac difficulty. Surgery is al-
ways indicated in embolization. We must re-
member that a commissurotomy may be only
temporary, and the patient may again come to
surgery at a later date should the valve re-
stenose. Surgery in mitral heart disease is con-
traindicated when the mitral insufficiency is the
predominant lesion. This may be diagnosed by
finding a loud systolic murmur at the apex. The

second pulmonic sound is not accentuated. The
left ventricle is enlarged clinically. The roent-
genogram reveals enlargement of the left ven-
tricle, and this can be confirmed by fluoroscopic
examination. An electrocardiogram shows left-
axis deviation with or without left heart strain.
The presence ol active rheumatic carditis, sub-
acute bacterial endocarditis, or other significant
cardiac lesions also contraindicate surgical in-
tervention.

Mitral insufficiency may be diagnosed as out-
lined previously. The value of surgical treatment
is questionable.

Tricuspid stenosis is usually congenital in ori-
gin and suggests the tetralogy of Fallot syn-
drome with the exception of the fact that the
electrocardiogram usually shows a left-axis de-
viation with left heart strain in contradistinction
to the right-axis deviation with heart strain. In
these cases, surgery should be attempted.

Coronary artery disease. A number of meth-
ods have been suggested for the surgical treat-
ment of this condition. Attempts to relieve the
pain have been made by paravertebral injections
of alcohol, Novocain, and the like. Cervical sym-
pathectomy has been suggested. Although these
procedures may alter the degree of pain, they,
in turn, however, are not without danger and
are not recommended. Direct attempts to revas-
cularize the heart have been many. It could
serve no purpose to list all these methods, for
it is my opinion that, at this time, no surgical
procedure is of value in the treatment of coro-
nary heart disease.

The Pericardium. Acute pericarditis may be
associated with the rapid accumulation of fluid
in the pericardial sac, producing a cardiac tam-
ponade. Depending upon the etiology of the
pericarditis, the fluid may be serous, purulent,
or a combination of both. As a result of the
rapid accumulation of fluid, the cardiac output
is decreased. There is a decrease in venous re-
turn to the heart. The venous pressure rises
rapidly, and the pulse becomes weak. Physical
examination reveals that the jugular veins are
greatly distended, the heart is silent, and the
cardiac dullness is increased. The electrocardio-
gram may show changes of pericarditis. The
roentgenogram shows a rather typical pear-
shaped type of heart, and fluoroscopic examina-
tion usually reveals absence of demonstrable pul-
sations. The removal of fluid is imperative. It
may be removed by puncture or by surgical
drainage. Treatment should then be directed
toward the cause of the pericarditis.

Chronic constrictive pericarditis. In this con-
dition, the heart is encased in a fibrous mass.

MARCH 1958

75

I he insidious onset of the disease makes diag-
nosis difficult. The patient is suggestive of an
individual with cirrhosis of the liver with the
exception that there is a pronounced increase
in the venous pressure. The physical findings
are those of an individual with congestive heart
failure, and the veins in the neck are markedly
distended. The heart is silent and usually small
and fixed in position. The x-ray examination re-
veals the small heart, and, occasionally, calcifica-
tion may be seen in the pericardium. The fluoro-
scopic examination and kymographic examina-
tion emphasize the decreased pulsations. Car-
diac catheterization often is of value because a
characteristic pressure curve may be present.
The electrocardiogram may suggest the diagnosis
because of the altered ST and T segments as well
as low voltage. Once the diagnosis is made, sur-
gery is indicated.

1 he heart may be injured by direct or indirect
trauma to the chest wall. One should always
be alert to the possibility of a laceration of the
heart, hemopericardium, or laceration of a valve.
Surgery should be immediate if indicated.

Tumors of the heart should be removed when
possible.

CONCLUSION

Many surgical procedures are available which
are of benefit to the cardiac patient. These pro-
cedures may be curative in some instances and
palliative in others. We must always be alert to
the benefits that may result from surgical inter-
vention. It is suggested that in the treatment
of heart disease, we must consider in each case
whether the patient is one in whom surgery can
complement or supplement our medical treat-
ment.

Cholesterosis of the gallbladder is caused by an aberration in cholesterol
metabolism. Lipoid material is most abundant in the villi of the mucosa but
may also be found in other layers of the gallbladder.

Abdominal pain, the most prominent svmptom, may be localized in the
right upper quadrant, the periumbilical region, or the epigastrium and is re-
ferred to the back or shoulder in about half of patients. Other symptoms in-
clude gaseous eructation, flatulence, nausea, vomiting, and intolerance to fried
and fattv food. Women are more frequently affected than men.

Cholecystitis is sometimes associated with cholesterosis; however, the latter
condition may cause symptoms without inflammation of the gallbladder.

Because cholesterosis does not produce fibrosis or impair concentration and
emptying, roentgenographic examination shows no abnormality in about one-
half of patients. When choleevstograms are normal but symptoms are charac-
teristic of gallbladder disease, duodenal drainage should be done. If micro-
scopic study shows cholesterol crystals in the B bile so obtained, the patient
has cholesterosis.

Removal of the diseased gallbladder will usually relieve symptoms. How-
ever, cholecystectomy should not be performed if the diagnosis cannot be
definitely established.

William F. Mitty, Jr., M.D., and Louis M. Rousselot, M.D., St. Vincent’s Hospital and New
York University, New York City. Gastroenterology 32:910-916, 1957.

76

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Acute Nonspecific Pericarditis

JAMES H. KELLY, M.D.
Minneapolis, Minnesota

Acute fibrinous pericarditis is an inflamma-
tion of the pericardium associated with the
formation of a fibrinous exudate on the pericar-
dial surfaces. The inflammatory process may sub-
side or progress and may be complicated by a
serous, serosanguineous, or purulent exudate.

Acute pericarditis may be classified into the
following groups:

1. Acute nonspecific pericarditis.

2. Infectious pericarditis,

a. Pyogenic pericarditis,

b. Tuberculous pericarditis,

c. Mycotic pericarditis,

d. Parasitic pericarditis.

3. Pericarditis occurring as a manifestation of
of the “collagen diseases.”

a. Rheumatic pericarditis,
b. Pericarditis accompanying rheumatoid
arthritis.

e. Pericarditis of disseminated lupus ery-
thematosus.

d. Pericarditis occurring in periarteritis no-
dosa.

4. Uremic pericarditis.

5. Pericarditis secondary to myocardial infarc-
tion.

6. Pericarditis due to neoplasm.

7. Traumatic pericarditis.

8. Rare forms of pericarditis of uncertain eti-
ology.1

This paper will deal with acute nonspecific
pericarditis, which is the collective name for
cases of acute pericarditis in which no systemic
or local causal agent can be demonstrated. It
is typically characterized bv antecedent infec-
tion of the respiratory tract, chest pain, fever,
tachycardia, pericardial friction rub, electro-
cardiographic changes, and a tendency toward
both pericardial and pleural effusion. It has been
referred to as idiopathic, epidemic, primary, non-
rheumatic, benign, relapsing, cryptic, fugitive,
and recurring pericarditis.2

This disease entity was probably first des-
cribed by Hodges in 1854. 3 In 1942, Barnes and
Burchell,4 of the Mayo Clinic, reported 14 cases

james h. kelly is a resident in internal medicine at
Veterans Administration Hospital, Minneapolis.

of acute nonspecific pericarditis simulating myo-
cardial infarction. Since that time, numerous
reports describing this disease have appeared in
the literature. This is probably due to its recog-
nition as a specific entity rather than to any act-
ual increase in the frequency of acute non-
specific pericarditis. It is a relatively rare dis-
ease. Only 1 reported series has included more
than 30 cases.5 The true incidence of this dis-
ease is difficult to ascertain. Diligent search for
specific etiology should be carried out in each
case. Its occurrence as a cause of acute pericar-
ditis has been reported to vary from 10 per cent11
to 33 per cent.7 These percentages can be ex-
pected to vary considerably, depending upon
the age, racial and socioeconomic status of the
group studied, as well as the physician’s aware-
ness of acute nonspecific pericarditis as a definite
entity.

DIAGNOSIS

Acute nonspecific pericarditis has generally been
thought to be a disease of young adults. How-
ever, cases have been reported that occured in
children8,9 as well as in patients in their seven-
ties.2 The average age at which this disease has
occurred is 35 to 40 years. 2 r',7,9,1° The disease
occurs in males 3 to 10 times more frequently
than in females. 2,11

Upper respiratory infections commonly pre-
cede the onset of acute nonspecific pericarditis.
The severity of such infection may vary from a
simple respiratory infection to an atypical pneu-
monia. Its incidence has been reported in from
37 to 54 per cent of cases, 2,r’-7,9 with 1 series re-
porting an incidence of 80 per cent."

Pain is the predominant symptom of acute
nonspecific pericarditis and occurs in practically
all patients at some time during the course of
their illness. Typically, it occurs rather abruptly
after an indefinite period of malaise. It is usually
substernal in location, with radiation to the left
chest and shoulder. The pain is accentuated by
deep respiration, cough, motion, and swallow-
ing.2 The difficulty in differentiating this pain
from that of acute myocardial infarction is ob-
viouslv great. The pain of acute nonspecific
pericarditis is generally less severe and less grip-
ping. Circulatory collapse is uncommon.5 Many

MARCH 1958

77

variations of this pattern of pain may occur. Two
cases presenting as acute abdominal conditions
in which surgical exploration was carried out
and 1 case presenting as low back pain have been
reported.2-12

Dyspnea is a prominent symptom in approxi-
mately one-half of the patients.2,5’7 5' It may be
present even in those patients who do not show
evidence of effusion or pulmonary infiltrate.
Severe pain caused by respiration may cause
rapid, shallow respiration.9

Fever is present in 80 to 90 per cent of the
reported cases.2-57'9 It should be emphasized,
however, that its presence is not essential in
establishing this diagnosis.9 The elevation of
temperature is usually in the range of 100 to 103°
F. Tachycardia is also common.

Pericardial friction rnb is the most important
physical finding and is present in over 70 per
cent of reported cases.2'5'7 9 '1 Typically, the rub
occurs early and may be transient or may last
for several days. If all patients could be ex-
amined at the time of onset of the first symptoms
of malaise, the reported incidence of pericardial
friction rub would probably be much higher.
The rub heard in acute nonspecific pericarditis
is typically scratchy and to-and-fro in nature.9
It is usually heard over a relatively large area
to the left of the sternum.2 A pericardial fric-
tion rub usually precedes electrocardiographic
changes.2 It is thought that the disappearance
of a friction rub is often coincident with the ap-
pearance of pericardial effusion.9

Leukocytosis is present in one- to two-thirds
of the cases,2'7 9 usually ranging from 10,000 to
15,000 cells per cubic millimeter. Leukopenia is
rare but has been reported.2 Elevation of the
sedimentation rate may be expected in from 70
to 90 per cent of cases. The highest sedimenta-
tion rate in any given case varied from 15 mm.
per hour to over 100 mm. per hour in one re-
ported series.7 The return of an elevated sedi-
mentation rate to normal has proved an accurate
index of improvement in clinical status.5

Electrocardiographic changes in pericarditis
are characteristic and are almost invariably pres-
ent and, therefore, are of great diagnostic value.
These changes are due to the pericarditis per se,
the extent of injury to the subepicardium and
possibly, to deeper layers of the myocardium,
and to the amount of pericardial effusion." The
elevation of the S-T segment with upward con-
cavity in one or more leads occurs early. Within
a period of a few days to a week, this elevation
returns to the normal isoelectric level. Shortly
thereafter, the T wave becomes inverted in
several of the limb and unipolar limb and chest

leads. A discordant relation of the T wave in
leads I and III occurs very seldom, and a signifi-
cant Q wave almost never appears.13 The in-
verted T waves usually become upright in six to
twelve weeks, but Carmichael reported 6 patients
with apparently permanent T wave inversion
following acute nonspecific pericarditis.5 Pro-
longation of the P-R interval, which is common
in rheumatic pericarditis, is not seen in acute
nonspecific pericarditis.7 Since a changing elec-
trocardiographic pattern is characteristic of peri-
carditis, the necessity of taking serial tracings
when this disease is suspected is obvious.

Enlargement of the cardiac silhouette as shown
by x-ray examination is a common finding in
acute nonspecific pericarditis. It is present ap-
proximately 50 per cent of the time.2'5 Much
controversy exists concerning whether the en-
largement of the cardiac silhouette represents
cardiac dilatation or pericardial effusion or both.
Ordinary roentgen examination usually does not
resolve the problem.7 Opinions in the literature
vary from stating that cardiac enlargement is
commonlv due to pericardial effusion2 to state-
ments that cardiac dilatation is the cause of
enlargement in 94 per cent of the cases.5 That
pericardial effusion can cause enlargement of the
cardiac silhouette has been proved by pericardio-
centesis.9 Cardiac tamponade in acute non-
specific pericarditis is relatively uncommon. For
this reason, pericardiocentesis has been per-
formed infrequently in this disease. Price and
associates,14 in reviewing this subject in 1956,
found reported records of only 20 pericardio-
centeses that had been performed in acute non-
specific pericarditis. In 10 of these patients,
serous fluid was obtained, and, in the other 10,
sanquineous effusions were present. In no case
was a sanquineous effusion reported before the
tenth day of illness. The use of angiocardio-
graphy has been suggested as a practical method
of differentiating pericardial effusion from card-
iac dilatation.15 Recent improvements in surg-
ical technics have made pericardial biopsy and
the creation of a pleuropericardial window prac-
tical.10 This method of treating cardiac tamp-
onade caused by pericardial effusion will prob-
ably replace pericardiocentesis in the future.
Therefore, angiocardiography diagnostically may
become increasingly important.

Approximately one-half of the patients show
evidence of pulmonary involvement, occuring
as pneumonitis, pleuritis, and/or pleural effu-
sion.2-7'9 Pleural effusion has been reported in 25
per cent of tbe cases.17 Effusions are usually left-
sided or bilateral. Right-sided effusions are un-
common.2 When pleural effusion is present, it

78

THE JOURNAL-LANCET

should, ot course, he examined in an attempt to
establish a specific etiology.

ETIOLOGY

The etiology of acute nonspecific pericarditis is
unknown, as its name implies. The widely differ-
ing course of the disease from one case to an-
other suggests that the condition can be caused
by more than one agent.7 It is generally felt that
acute nonspecific pericarditis is a viral disease,
although a specific virus has as yet not been
identified. That viruses can cause pericarditis
has been shown by its coincident occurrence in
diseases of known viral etiology. Instances have
been reported of its occurrence in association
with lymphogranuloma venereum,18 Bornholm
disease,19 and primary atypical pneumonia.20 A
relationship between acute nonspecific pericar-
ditis and infectious mononucleosis has also been
reported.2122 Evidence supporting the virus
theory is the antecedent respiratory infection,
the occasional occurrence of the disease in epi-
demics, and its usually benign course. Against
the viral etiology is the fact that virus organisms
have never been recovered from a pericardial
effusion.9 Significant cold agglutinin titers in
patients with acute nonspecific pericarditis rarely
occur.2,7 The usual lag between the respiratory
infection and the pericarditis and the usual pres-
ence of leukocytosis also mitigate against the
virus theory of etiology.

Dressier'" has suggested that acute nonspecific
pericarditis is of rheumatic etiology. He stresses
its great similarity to the postcommissurotomy
syndrome, which is thought to be of rheumatic
origin. He also stresses the fact that acute rheu-
matic fever in adults is often an atypical, benign
process which may heal without residual heart
disease. This and the fact that acute nonspecific
pericarditis is primarily a disease of adults, he
feels is more than mere coincidence. Against the
rheumatic theory is the infrequency of joint in-
volvement in this disease. A history of acute
rheumatic fever in the past is rare. When peri-
carditis does occur in acute rheumatic fever, it
seldom becomes manifest before the joint symp-
toms are noted.23 No pathologic evidence of
rheumatic disease has been obtained in cases
of acute nonspecific pericarditis which have
come to surgery or necropsy.2

Tuberculosis has often been advanced as an
etiologic explanation of acute nonspecific peri-
carditis. The well-known fact that pericarditis,
as well as pleural and pericardial effusions, may
occur with tuberculosis and may defv specific
diagnosis for long periods of time favor this
theory. Aganist this theorv is the fact that peri-

carditis in tuberculosis is usually painless and
seldom, if ever, runs a benign course. Surprising-
ly, little information is available in the literature
regarding the incidence of positive tuberculin
reactions in acute nonspecific pericarditis. One
author states the tuberculin reaction is often
negative.5 Another reports 5 positive reactors in
10 patients.2

Many other etiologic theories have been postu-
lated. Cases have been reported occurring in
allergic diseases.24 Toxins have been implicated
by some who point to the frequent occurrence
of pericarditis in uremia to support this hypo-
thesis. The relationship of acute nonspecific
pericarditis to polyserositis and to various types
of arteritis is often mentioned but has not been
fully investigated in either instance.9

PATHOLOGY

Although pathologic reports in acute nonspecific
pericarditis are few in number, owing to its gen-
erally benign course, those reports that are avail-
able all establish the pericardial nature of the
disease. An organizing, nonspecific pericarditis
is found. Coronary vessels and myocardium are
grossly normal. Polymorphonuclear leukocyte in-
filtration of the myocardium adjacent to the
epicardium has been described.9

DIFFERENTIAL DIAGNOSIS

The diagnosis must be made by carefully exclud-
ing other forms of acute pericarditis and other
diseases which cause chest and abnominal pain.
The specific causes of acute pericarditis listed
in the introduction often become apparent after
an adequate history has been taken, a physical
examination has been done, and appropriate
laboratory studies have been obtained. The pres-
ence of pain alone, however, introduces a large
number of diagnostic possibilities, including myo-
cardial infarction, coronary insufficiency, pneu-
monia, pleuritis, mediastinitis, pleurodynia, her-
pes zoster, intercostal neuralgia, diaphragmatic
hernia, and acute abdominal conditions.9 Of
these, the most important by far and often the
most difficult to differentiate is acute myocardial
infarction. The treatment and prognosis in acute
nonspecific pericarditis anti acute myocardial in-
farction are quite different, as will be noted.
Krook7 reviewed the cases of acute myocardial
infarction occuring in patients under the age of
45 at Mahno General Hospital in Sweden from
1943 to 1952 anti found that 4 cases were diag-
nosed acute myocardial infarct, where as, in
retrospect, these patients actually had had acute
nonspecific pericarditis. In general, this exper-
ience has probably been the rule rather than the

MARCH 1958

79

exception. The onset, location, and radiation of
pain may be similar in both diseases, but the
accentuation of pain by motion, respiration, and
coughing favors pericarditis. The pain is usually
more severe in myocardial infarction, and cir-
culatory collapse is more common. Both diseases
occur predominantly in males, but acute non-
specific pericarditis occurs generally in a younger
age group. History of an antecedent upper res-
piratory infection and/or the presence of pul-
monary inflammation, as well as the early ap-
pearance of a pericardial friction rub, all favor
the diagnosis of acute nonspecific pericarditis.
Leukocytosis and elevation of the sedimentation
rate occur earlier in pericarditis. The importance
of serial electrocardiograms when this diagnostic
problem arises cannot be overemphasized. Trans-
aminase determinations may become an increas-
ingly useful diagnostic study, often being ele-
vated in myocardial infarction and normal in
pericarditis.

Dressier25 recently reported 10 cases of pleuro-
pericarditis after proved myocardial infarction
which have closely mimicked acute nonspecific
pericarditis, which he calls the "post infarction
syndrome.’ Its significance is not as vet clear.

COURSE AND PROGNOSIS

The natural course of acute nonspecific pericar-
ditis may be summarized in the following man-
ner. It is usually a benign disease. Recurrences
are frequent. Late chest pain is common. Con-
strictive pericarditis is seldom a late complica-
tion. The electrocardiogram may occasionally
show persistent abnormalities.

This disease usually runs a benign course,
lasting anywhere from two to seventv days with
an average of approximately two weeks. How-
ever, 5 fatal cases have been reported in the
literature.14’26-29 Cardiac tamponade, although
rare, should be watched for carefully because
pericardiocentesis or the surgical creation of a
pleuropericardial window may be lifesaving in
such a situation.

Recurrences have been reported in 15 to 35
per cent of the cases. 2-i r,’7 ° Recurrent episodes
of acute nonspecific pericarditis are usually less
severe than the initial attack and are seldom pre-
ceded by an upper respiratory infection. Tran-
sient bouts of vague chest pain of varying inten-
sity, occurring months and even years after the
initial illness, have been even more common in
the few patients in whom an adequate follow-up
has been possible.5

Although all authors agree that constrictive
pericarditis is a rare sequal to acute nonspecific
pericarditis, opinions differ greatly as to whether

it actually happens. Dalton and associates,30 in
reporting 78 cases of constrictive pericarditis,
stated that an intensive study was not made to
elucidate the etiology of the disease. However,
one fact stood out, and that was that when the
etiology was unequivocal, it was invariably tuber-
culous. Carmichael,31 in 1955, stated that no
well documented cases of chronic constrictive
pericarditis occuring after acute nonspecific peri-
carditis had been reported. Rabiner and associ-
ates32 reported a case of a patient in whom con-
strictive pericarditis developed after nonspecific
pericarditis, who was treated surgicallv with good
results. Many aspects of the case, however, sug-
gested a tuberculous etiology. In another series
of surgically treated patients with pericardial
effusion, Proudfit and Effler16 reported 5 cases of
sanquineous pericardial effusion of undetermined
etiology. They suggested that chronic constric-
tive pericarditis would probably have developed
later in these patients. Krook7 feels that the late
sequelae of constrictive pericarditis is more fre-
quent than we suspect and reports 2 such cases
occurring after acute nonspecific pericarditis.
He also points to the high frequency with which
adherent pericarditis is found at autopsy in pa-
tients dying of other causes and the fact that in
only a relatively small percentage of such cases
was a history of pericarditis due to a specific
etiology elicited in their medical history.

Three patients showing evidence of residual
myocardial injury long after the initial acute
nonspecific pericarditis had subsided have been
reported.17 Persistent, apparently permanent,
electrocardiographic changes have been reported
in as much as 12 per cent of the patients.5 These
changes have consisted primarily of abnormal T
wave inversions. The appearance of such T wave
abnormalities in an otherwise healthy young
male suggests the possibility that an undiagnosed
acute nonspecific pericarditis has occurred at
some time in the past.

TREATMENT

The treatment of acute nonspecific pericarditis
is symptomatic. Patients may be ambulated as
soon as their symptoms allow, although activity
should be limited until all signs and symptoms
of their disease have disappeared.2 Because of
the potential complication of hemorrhagic peri-
cardial effusion,1416 which may be fatal,27 29 the
use of anticoagulants is definitely contraindicated
and again emphasizes the importance of earlv
accurate diagnosis of this disease.

There is an occasional report in the literature
suggesting that antibiotics are of value in treat-
ment.33'34 Most authors, however, are of the

80

THE JOURNAL-LANCET

opinion that antibiotics are of no specific bene-
fit.35'36

The use of corticotrophin and cortisone has
been reported in the treatment of patients with
acute nonspecific pericarditis who were very
toxic and steadily becoming more ill. Reports
of at least 12 patients so treated are available.2’8'
0,37-39 jn ajj |1U(- one instance,9 the course of the
patient’s illness promptly improved and the pa-
tient recovered. When cortisone was discon-
tinued, one patient38 suffered a relapse but re-
sponded when cortisone therapy was resumed
and remained well after it was gradually discon-
tinued three weeks later. It is postulated that
the steroid therapy suppresses inflammatory re-
sponses during the acute phase of the illness but
does not otherwise alter the natural course or
duration of the disease.8 It would seem that the
use of steroids in a dosage equivalent to 25 mg.
of cortisone four times a day is indicated in a

REFERENCES

1. Cecil, R. L., and Loeb, R. F.: Textbook of Medicine, ed. 9.
Philadelphia, W. B. Saunders Co., 1955.

2. Scherl, N. D.: Acute nonspecific pericarditis; survey of the
literature and study of 30 additional cases. J. Mt. Sinai Hosp.,
N. Y. 23:293, 1956.

3. Hodges, R. M.: Idiopathic pericarditis. Boston Med. & Surg.
J. 51:140, 1854.

4. Barnes, A. R., and Burchell, H. B.: Acute pericarditis sim-
ulating acute coronary occlusion. Am. Heart J. 23:247, 1942.

5. Carmichael, D. B., Sprague, H. B., Wyman, S. M., and

Bland, E. F.: Acute nonspecific pericarditis. Clinical, lab-

oratory and follow-up considerations. Circulation 3:321, 1951.

6. Reeves, R. L.: Cause of acute pericarditis. Am. 1. M. Sc.

225:34, 1953.

7. Krook, H.: Acute nonspecific pericarditis; study in 24 cases

including descriptions of 2 with later development into con-
strictive pericarditis. Acta med. scandinav. 148:201, 1954.

8. Friedman, S., Ash, R., Harris, T. N„ and Lee, H. F.:
Acute benign pericarditis in childhood; comparisons with rheu-
matic pericarditis, and therapeutic effects of ACTH and cor-
tisone. Pediatrics 9:551, 1952.

9. Reid, E. A. S., Hutchison, J. L., Price, J. D., Smith, R. L.:
Idiopathic pericarditis. Ann. Int. Med. 45:88, 1956.

10. Dressler, W.: Idiopathic recurrent pericarditis; comparison

with postcommissurotomy syndrome; consideration of etiology
and treatment. Am. J. Med. 18:591, 1955.

11. Goyette, E. M.: Acute idiopathic pericarditis. Ann. Int.

Med. 39:1032, 1953.

12. Powers, P. P., Read, J. L., and Porter, R. R.: Acute idio-
pathic pericarditis simulating acute abdominal disease.
J.A.M.A. 157:224, 1955.

13. Gelfand, M. L., and Goodkin, L.: Acute benign nonspecific
pericarditis without a pericardial friction rub. Ann. Int. Med.
45:490, 1956.

14. Price, J. D., Hutchison, J. L., and Reid, E. A. S.: Benign
idiopathic pericarditis; fatal case with a review of the fatalities
in the literature. Am. Heart J. 51:628, 1956.

15. McGuire, J., and others: Nonspecific pericarditis and myo-

cardial infarction. Circulation 14:874, 1956.

16. Proudfit, W. L., and Effler, D. B.: Diagnosis and treat-
ment of cardiac pericarditis by pericardial biopsy. J.A.M.A.
161:188, 1956.

17. Godfrey, J.: Myocardial involvement in acute nonspecific

pericarditis. Ann. Int. Med. 35:1336, 1951.

18. Sheldon, W. H., Wall, M. J., Slade, J. De R., and Hey-
man, A.: Lymphogranuloma venereum in a patient with
mediastinal lvmphadenopathv and pericarditis. Arch. Int.
Med. 82:410,' 1948.

19. Bower, B. D., Gerrard, J. W., and MacGregor, M.: Acute
benign nonspecific pericarditis; report of 4 cases in childhood.
Brit. M. J. 1:244, 1953.

20. Finkelstein, D., and Klainer, M. J.: Pericarditis associated

severely ill patient.38 The evaluation of such non-
specific therapy in a usually benign disease must
be evaluated critically and such therapy should
not be used indiscriminately. We must remem-
ber that the use of a “blister” one century ago
was thought to be helpful specific therapy.3

SUMMARY

1. The incidence and diagnosis of acute non-
specific pericarditis have been discussed.

2. The most prevalent theories of etiology have
been presented.

3. The difficulty and importance of differenti-
ating acute nonspecific pericarditis from acute
myocardial infarction have been emphasized.

4. Recurrences are common, but late compli-
cations in acute nonspecific pericarditis are rare.

5. Treatment is symptomatic. The careful use
of corticotrophin or cortisone may be indicated
in selected cases.

with primary atypical pneumonia. Am. Heart J. 28:385,
1944.

21. Miller, H., Uricchio, J. F., and Phillips, R. W.: Acute

pericarditis associated with infectious mononucleosis. New
England J. Med. 249:136, 1953.

22. Soloff, L. A., and Zatuchni, J.: Infectious mononucleosis

associated with symptoms of acute pericarditis. J.A.M.A. 152:
1530, 1953.

23. Furman, R. H.: Acute nonspecific pericarditis. Am. Pract.

& Digest Treat. 3:869, 1952.

24. Zivitz, N., and Oshlag, J. A.: Eosinophilic pleural effusion
and pericarditis with effusion in an allergic subject. J. Aller-
gy 20:136, 1949.

25. Dressler, W.: A complication of myocardial infarction re-

sembling idiopathic recurrent benign pericarditis. Twenty-
eighth scientific session, Am. Heart Assoc., New Orleans, Oct.
24, 1955, Abst., Circulation 12:697, 1955.

26. Pomerance, M., Perchuk, E., and Hoffman, J. B.: Fatal

case of idiopathic pericarditis. New York J. Med. 52:95,
1952.

27. McCord, M. C., and Taguchi, J. T.: Nonspecific pericarditis;
a fatal case. Arch. Int. Med. 87:727, 1951.

28. Case records of Mass. Gen. Hosp. New England J. Med.
234:608, 1946.

29. Case records of Mass. Gen. Hosp.; weekly clinicopathologic ex-
ercises. New England J. Med. 254:707, 1956.

30. Dalton, J. C., Pearson, R. J., Jr., and White, P. D.: Con-
strictive pericarditis; review and long term follow-up of 78
cases. Ann. Int. Med. 45:445, 1956.

31. Carmichael, D. B.: Natural course of acute nonspecific peri-
carditis. U. S. Armed Forces M. J. 6:534, 1955.

32. Rabiner, S. F., Specter, L. S., Ripstein, C. B., and
Schlecker, A. A.: Chronic constrictive pericarditis as sequel
to acute benign pericarditis; report of case. New England
J. Med. 251:425, 1954.

33. Taubenhaus, M., and Brams, W. A.: Treatment of acute

nonspecific pericarditis with aureomycin. J.A.M.A. 142:973,
1950.

34. Marois, A., and Marcoux, G.: Acute benign nonspecific

pericarditis. Canad. M. A. J. 75:834, 1956.

35. Parker, R. C., Jr., and Cooper, H. R.: Acute idiopathic

pericarditis. J.A.M.A. 147:835, 1951.

36. Christian, H. A.: Nearly 10 decades of interest in idiopathic
pericarditis. Am. Heart j. 42:645, 1951.

37. Kursban, N. J., and Iglauer, A.: Acute nonspecific peri-

carditis: report of case treated with ACTH. Ohio M. J. 47:
915. 1951.

38. Rakov, H. L.: Acute nonspecific idiopathic pericarditis; re-

port of case treated with orallv administered cortisone. Arch.
Int. Med. 98:240, 1956.

39. Weiss, M. M.: Acute idiopathic pericarditis treated with cor-
tisone. J. Kentucky M. A. 50:393, 1952.

MARCH 1958

81

Spontaneous Subarachnoid Hemorrhage

RUDOLPH J. RIPPLE, JR., M.D.

St. Paul, Minnesota

Subarachnoid hemorrhace is typically defined
as a sudden onset of headache, often with the
feeling that something has snapped in the head
and followed by a greater onset of severe oc-
cipital pain, nausea, and vomiting with pro-
nounced rigidity of the neck muscles, positive
Kernig’s and Brudzinski’s signs, and blood by
spinal puncture. These symptoms are caused by
free blood in the subarachnoid space.

INCIDENCE

Spontaneous subarachnoid hemorrhage is said
to be responsible for 2 per cent of sudden un-
explained deaths.1 Baker- savs that it is the
second most common cause of central nervous
system deficit in the young adult age group. The
sex incidence in various series shows that the
distribution is just about equal.

The disease is generally conceded to have an
incidence of about 1/15 that of a cerebrovascular
accident ( thrombosis or intracerebral hemor-
rhage). Berg3 noted that polycystic disease of
the kidney is definitely associated with berry
aneurysms (one of the causes of spontaneous
subarachnoid hemorrhage). He found aneu-
rysms could be noted in 1 per cent of autopsies,
but, in patients with polycystic kidney disease,
16 per cent had intracranial aneurysms at autop-
sy. He also feels there is an association between
intracranial aneurysms and hypertension, coarc-
tation, and patent ductus arteriosus.

ETIOLOGY

The etiology of subarachnoid hemorrhage varies
to a degree with different authors because of
their exclusion of different entities. Trauma and
birth injury are excluded by the definition “spon-
taneous.” Therefore, anything that produces
blood in the subarachnoid space fits the classifi-
cation. Included in the causes are extension of
an intracerebral hemorrhage into the subarach-
noid space, arteriosclerosis, congenital aneu-
rysms, syphilis, septic emboli, angiomas, blood
dyscrasias, acute hemorrhagic infections, eclamp-
sia, tumors, thrombosis of a longitudinal sinus,
and even subdural hematoma. In most of these

rudolph j. ripple, jR. w a medical resident at the
Veterans Administration Hospital, Minneapolis.

conditions, however, very small amounts of
blood appear in the subarachnoid space. Gross-
ly bloody fluid usually indicates rupture of a
blood vessel in the subarachnoid space— usually
an aneurysm, arterial angioma, or arteriovenous
malformation. Walton,4 excluding atherosclerotic
intracerebral hemorrhage bursting into a ven-
tricle, trauma, and birth, listed these factors as
the causes of the disease: aneurysmal rupture,
80 per cent, rupture of an angioma or arterio-
venous malformation, 10 per cent, and other con-
ditions, 10 per cent.

This discussion will be concerned with the two
former conditions.

CLINICAL FEATURES

There is scarcely a more dramatic syndrome in
its onset and development than subarachnoid
hemorrhage. Most authors do not correlate ex-
ercise with onset, but, in McCutchan’s1 pa-
tients, two-thirds were working hard at time of
onset. The characteristic symptoms of this dis-
ease are the result of blood irritating the me-
ninges and increasing the cerebrospinal fluid
pressure. There are, however, general systemic
symptoms, localizing symptoms in some cases,
and some which suggest etiology.

The symptoms caused by blood entering the
subarachnoid space depend on the speed at
which the bleeding occurs. If bleeding occurs
slowly, the patient may have onlv a headache
and stiff neck for a week, or he may rapidly
lose consciousness within a few minutes if the
blood loss is sufficiently extensive. In the average
case, there is an acute onset of a violent head-
ache, often accompanied by a feeling that some-
thing has snapped inside the head, and followed
by vertigo, vomiting, and stiffness of neck in 50
per cent of cases. Most patients pass at least
into a state of semistupor, but some never lose
consciousness. The majority of patients lie in an
attitude of general flexion, resent interference,
and are confused and irritable when aroused.
During this period, moderate pyrexia is com-
mon, photophobia is not unusual, and seizures
occur in 3 per cent.4 Findings due to the in-
creased intracranial pressure include papillede-
ma, which is usually slight, occurring most often
on the side of the hemorrhage, though it may

82

THE JOURNAL-LANCET

he bilateral. Subhyaloid hemorrhages are not
uncommon. Fundi changes are usually related
to the proximity of the optic nerves to the hem-
orrhage. Other nonlocalized findings are those of
third or sixth nerve palsies and diminution of
tendon and abdominal reflexes.

Localized findings are most frequent when the
etiologic bleeding point is closely applied to
brain substance, that is, anterior communicating
and middle cerebral ruptures are more likely to
cause localization than rupture of the internal
carotid artery, which is loose in the subarach-
noid space.

Focal symptoms are more likely to occur with
rupture of an arteriovenous malformation, in the
ratio of 8:1, but these are, of course, of no help
in diagnosing the individual case.

Premonitory signs occur most often with the
angiomatous malformation but also can occur
with aneurysms, consisting of visual field defects,
focal seizures, previous bleeding episodes, and
migrainous-type headaches. Laboratory findings
include pvrexia, leukocytosis, occasional albumi-
nuria and glycosuria, and increased spinal fluid
pressure. For two to three days, the fluid is
grossly bloodv and, providing bleeding stops, is
xanthochromic for about two to three weeks.
The protein content is elevated, though rarely
above 100 mg. There can be up to 3,000 white
blood cells in the fluid ( dilution of the blood ) .

The diagnostic workup should include skull
roentgenograms and an electro-encephalogram,
although usually both are noncontributory. The
skull film may occasionally show calcification in
the case of an angioma. The differential diag-
nosis is only in doubt in the occasional case in
which the patient is so comatose that his neck
is not stiff, in which case, the diagnosis is that
of the comatose patient. Ordinarily, the only
question is that of meningitis, and the spinal
tap for pressure, cells, culture, smear, and pro-
tein rules this condition out. Incidentally, menin-
geal irritation is the one indication for spinal tap
with choked disk. However, even then it can
cause herniation of the medulla and should be
carefully performed.

There is some differential symptomatology of
angioma versus aneurysm, and these findings
differ to a certain degree with the position and
pathology. Let us first discuss the aneurysm.

Intracranial aneurysm. Pathologically, the
berry aneurysm is a 1 to 5 mm. (up to 30 mm.)
swelling at the junction of two of the compo-
nents of the circle of Willis or at a bifurcation
of one of the cerebral arteries. Brain5 feels that
the aneurysm may be congenital, but it is apt
to develop at any time in life on the basis of

congenital structural deficiency, that is, a weak-
ness in the media. Microscopically, these media
are extremely narrow and fibrous, and the elastic
and muscular elements are absent. Brain states
that 80 per cent of these rupture sooner or later,
but Hamby0 reports an autopsy incidence in all
patients of about .5 to 1 per cent. Aneurysms
are felt to be multiple in 15 per cent of cases.

Where are the lesions most likely to occur?
Again, this is difficult to assess as they are listed
as ruptured, unruptured, and arteriosclerotic, in-
clusive, in different series. A fairly typical series
of locations of ruptured aneurysms is that found
in Baker’s- book, which lists McDonald’s series
of 786 cases.

Anterior communicating, 109
Middle cerebral, 247
Anterior cerebral, 75
Internal carotid, 106

| unction of internal carotid and posterior communi-
cating, 26

| unction of anterior cerebral and anterior communi-
cating, 28

Posterior communicating, 29
Posterior cerebral, 23
Basilar, 89
Vertebrals, 42

The posterior fossa ruptures are felt to con-
stitute about 25 per cent of the ruptures.

It has been previously mentioned that aneu-
rysms are less likely to cause symptoms prior
to rupture than arteriovenous malformations,
but Brain5 feels that 25 per cent may cause
symptoms prior to rupture. However, recurrent
headache is the symptom he lists as most
frequent, which makes it valueless as a diagnos-
tic, localizing procedure. Internal carotid aneu-
rysms, however, may produce visual field de-
fects. Middle cerebral aneurysms may cause
monoplegia and hemiplegia and result in con-
vulsions prior to rupture. Posterior fossa (ver-
tebral and basilar arteries) may cause crossed
hemiplegia.

Angiomatous malformations. These are rarer
than aneurysms, of course, being responsible for
about 1 per cent of neurologic admissions. They
are best divided into 3 types:

1. Telangiectasis is a small group of dilated
capillaries. The condition occurs in Rendu-Osler-
Weber disease. Of rare significance clinically in
rupture because it rarelv causes symptoms.

2. Venous angiomas are wedge- or cone-
shaped masses of veins which may be superficial
but usually extend deeply into white matter.
These too are uncommon causes of hemorrhage.
These produce no bruit and do not enlarge
because they have no arterial supply. They are
relatively less symptomatic than the next group.

3. Arterial angioi7ias ( arteriovenous aneurysms)

MARCH 1958

83

are also wedge-shaped lesions extending deep
into the brain parenchyma. They are sup-
plied with blood by one or more large arteries.
For that reason, they can enlarge. Also, they
may contain arteriovenous fistulae. They are
composed of arterial-like vessels, as opposed to
the venous angiomas. The arteriovenous fistulae
in these lesions may be of sufficient magnitude
to cause heart failure.1

These lesions are predominantly in the domain
of the middle cerebral artery, thereby contrib-
uting to their seriousness. Because of this com-
mon distribution in one-half of them, a frequent
presenting symptom is epilepsy. Because of
their intracerebral nature, these lesions are much
more apt to produce symptoms prior to a hem-
orrhage. Of differential diagnosis, there are, ac-
cording to Mackenzie,7 ( 1 ) multiple previous
bleeding episodes and (2) focal seizures. These
factors greatly favor ruptured arteriovenous mal-
formation over a ruptured berrv aneurysm, as do
(3) progressive neurologic deficit prior to hem-
orrhage, (4) bruit, which is diagnostic, and (5)
migrainous headaches prior to hemorrhage, but
these conditions can occur too with an internal
carotid aneurysm.4 During the acute hemor-
rhage, the ruptured arteriovenous lesion usually
causes more direct brain damage because of its
location, but this is not of help in the diagnosis of
an individual patient. In 70 per cent of patients
with angiomas, the first symptom occurs before
age 30.

TREATMENT

There are almost as many methods of treatment
as there are authors, and lack of controlled
studies is to be expected because of the emer-
gent nature of the disease and the fact that each
patient must be treated individually.

Most physicians feel that the patient should
be treated conservatively until the bleeding
stops. The patient should be made as comfort-
able as possible and restlessness should be al-
layed so that further bleeding will not occur.
Phenobarbital and codeine are indicated. Hour-
ly vital signs should be observed, and tempera-
ture must be taken each four hours because fever
is often the first sign that bleeding has recurred.
Walton4 feels that lumbar puncture should not
be used as a daily routine treatment, not so
much because it may cause bleeding to recur
but because he feels the procedure is of no bene-
fit and may introduce herniation of the medulla,
fie repeats lumbar puncture only for intense
symptomatology, the inspection of continued
fresh bleeding, or evaluation of surgical treat-
ment. Most all authors believe in taking only

a few cubic centimeters, which can be used for
cell-count culture and protein, and the pressure
can still be reduced somewhat for comfort.
Fluids, of course, should be given to maintain
the electrolyte situation. From this point on,
the treatment varies. If the patient fails rapidly,
some authors feel that nothing can be done.8
Others feel that immediate carotid ligation in the
neck should be done as an emergency measure.

Usually, however, after the third day, the
bleeding has stopped, and most authors feel
that angiography is indicated. Bilateral carotid
angiography should be done because 20 per
cent of aneurysms are multiple, and, in the case
of anterior aneurysms, one must know the
source from which they are fed and on which
side they are located. Twenty per cent of the
carotid angiograms are negative. Basilar angio-
grams are felt to be indicated by some. Others
do not believe they are worthwhile because of
the difficulty in assessing them surgically. The
angiogram can demonstrate both aneurysms and
arteriovenous malformations.

Norlen and Olivecrona8 feel that the time for
surgery in at least one-half of the patients should
be between three to fourteen days after hemor-
rhage occurs, because after that the vessels di-
late, the clot loosens, and bleeding is most apt
to recur. This is the point at which treatment
of the angiomatous malformation and the berrv
aneurysms differ.

The aneurysms differ as to location:

1. Intracranial internal carotid aneurysms are
the easiest to attack surgically by the intracra-
nial trapping method and comprise about 25
per cent of all aneurysms.

2. Anterior communicating and anterior cere-
bral aneurysms include 28 per cent of demon-
strated aneurysms. These are more difficult to
treat, particularly because they feed from both
sides in so many instances. French9 has had
much success in treating this tvpe.

3. Middle cerebral aneurysms comprise 30
per cent of these lesions. Their prognosis is poor
because of the difficulty in trapping the aneu-
rysm and the resultant hemiplegia."

4. Vertebral and basilar arteries offer little
surgically, but some authors have done vertebral
artery ligation with success.10

The surgical attack on aneurysms, as well as
on malformations, is the only real hope for im-
provement in prognosis. The majority of authors
feel that the attack on intracranial aneurysms is
no better than conservative measures in the first
three days but that it provides protection against
later recurrence.11 Recurrences can occur as late

84

THE JOURNAL-LANCET

as twenty years after the original hemorrhage.

Surgical attacks on angiomas or arteriovenous
malformations are at best rather poor because of
the deep infiltrating nature of the lesions. A few
respond to radiation. Carotid ligation is not so
valuable. Block resections of areas of the brain
have been performed with some success. Occa-
sionally, tying off a feeding vessel can help, but
it is difficult to decide and be sure whether it
is the only feeding vessel.

There is no really controlled series from which
to determine whether surgery is better than med-
ical treatment because no group contains the
same patients. Falconer cites mortality rates of
50 to 60 per cent in conservatively treated pa-
tients as against 20 per cent after surgery. How-
ever, his was a group of only 50 patients. Most
authors believe that surgery offers the only hope
for increasing recoveries after the first three days.

PROGNOSIS

The prognosis is worse, of course, with increas-
ing age,4 recurrent bleeding, and severe neuro-
logic signs. Most authors found that about one-
third of nonsurgically treated patients died dur-
ing the first attack and 20 per cent more after
a recurrence in the second week.12

Hamby’s report'-’ shows, in 130 cases treated
conservatively, a 45 per cent mortality with
first attack and 72 per cent of survivors in the
second attack. Symptoms which seem to pre-
dispose to poor prognosis in the first attack in-
clude coma for more than one day, high blood
pressure, hemiplegia, high temperature, recur-
rent fever, and convulsions.4 Hvland13 feels, like
others, that an angiomatous etiology presents a
much graver situation because the brain tissue
is much more apt to be involved. Walton col-
lected 1,300 cases throughout the literature and
found that 581 (44.7 per cent) died in the first
eight weeks, which included the first recurrence.

REFERENCES

1. McCutchan, G. R.: Spontaneous subarachnoid hemorrhage.

Am. J. Med. 17:528, 1954.

2. Baker, A. B.: Clinical Neurology. New York: Paul B.

Hoeher, Inc., 1955.

3. Berg, R. L.: Subarachnoid hemorrhage; case report. New

England J. Med. 252:594, 1955.

4. Walton, J. N.: Prognosis and management of subarachnoid
hemorrhage. Canad. M. A. J. 72:165, 1955.

5. Brain, Sir Russell: Diseases of the Nervous System. Lon-
don: Oxford University Press, 1955.

6. Hamby, W. B.: Intracranial Aneurysms. Springfield, Illi-

nois: Charles C Thomas, 1952.

7. Mackenzie, I.: Clinical presentation of cerebral angioma.

Brain 76:184, 1953.

Of his own group, Walton says that of the 120
survivors he was able to follow, 4 per cent were
completely disabled. Of the rest, one-third had
fairly serious sequelae, consisting of paralysis
10 per cent, convulsions 13 per cent, severe head-
ache 37 per cent, mental deterioration 9 per cent,
and anxiety 27 per cent. Another one-third had
trivial sequelae and one-third had no symptoms.
Comparative studies are very hard to analyze in
those who have had surgery because of differ-
ences in age, surgical technic, location of aneu-
rysm, and the type of operation. However, the
general impression is that the prognosis is better
after the first three days.2 In Falconer’s series
of 50 who were treated surgically, mortality was
only 20 per cent, and only 3 patients were dis-
abled after surgery. Not as great a number of
series has been treated surgically as conserva-
tively, and, in medical series, reports varied from
28 to 63 per cent deaths. For that reason, statis-
tics at present mean little. In Jacobson’s14 group
of medically treated patients, 11 per cent of
those who recovered were permanently maimed.
The prognosis of recurrence after the first six
months of those who live another six months
is only 10 per cent.4 The prognosis in surgically
treated patients varies with the site and type
of operation, but it is felt that surgery greatly
decreases the possibility of later bleeding.

SUMMARY

Some factors about symptoms and prognosis of
subarachnoid hemorrhage have been discussed.
It is apparent that longer periods of study are
required before final conclusions can be drawn
concerning the most effective type of treatment.
Spontaneous subarachnoid hemorrhage is a seri-
ous disease with a rather poor prognosis. It is
felt that surgical technics reduce the death rate
to some extent and offer the greatest hope of
cure.

8. Norlen, G., Olivecrona, H.: Treatment of aneurysms of

circle of Willis. J. Neurosurg. 10:404, 1953.

9. French, L.: Personal communication.

10. Falconer, M. A.: Surgical treatment of bleeding intracranial
aneurysms. J. Neurol., Neurosurg. & Psychiat. 14:153, 1951.

11. Rowe, S. N., Grunnagle, J. F. and others: Results of direct
attack on intracranial aneurysm. J. Neurosurg. 12:475, 1955.

12. Cecil, R. L., and Loeb, R. F.: Textbook of Medicine, ed. 5.
Philadelphia: W. B. Saunders Co., 1956.

13. Hyland,. H. H.: Prognosis in spontaneous subarachnoid

hemorrhage. Arch. Neurol. & Psychiat. 63:61, 1950.

14. Jacobson, S. A.: Analysis of some factors in spontaneous

subarachnoid hemorrhage. Arch. Neurol. & Psychiat. 72:712,
1954.

MARCH 1958

85

Rectal Bleeding in Infants and Children

J. C. RATHBUN, M.D., F.R.C.P.(C).

London, Ontario

Rectal bleeding is a fairlv common com-
plaint in an office practice dealing with in-
fants and children. In hospital practice, on the
other hand, it is a much less common but much
more serious sign. Blood in the stool is always
disturbing to parents and, fortunately, leads
them to the physician. Because of the grave
implications in hospital cases and the necessity
for the physician to decide between serious and
benign lesions, it is important that all of these
children be regarded carefully. Any case of
rectal bleeding demands a detailed history and
physical examination with a rectal and procto-
scopic examination when indicated. Even with
the most careful study, some 10 to 20 per cent
of cases cannot be clearly diagnosed. For this
reason, the examination must be meticulous in
all details.

In taking the history of these patients, it is im-
portant to learn the nature of the blood passed:
its color, whether clotted or not, whether mixed
with stool or not, whether there is mucus or pus,
its amount and duration, and any associated
symptoms. The relationship to the bowel move-
ment may be helpful. This detailed description
of the stool must be obtained. If possible, the
physician should see the stool himself.

Armed with this information, a differential
diagnosis can be outlined which precludes cost-
ly mistakes. As a general rule, bright red blood
passed by the bowel has been said to come from
the lower portion of the gastrointestinal tract,
and, although this is generally true, it may prove
wrong in specific cases. The various causes of
rectal bleeding are shown in table 1. These are
grouped according to the appearance of the
blood in the stool. The first column shows the
commoner causes of bright red blood in the stool,
and the second column shows the rarer causes.

To avoid errors of omission, all these diag-
noses must be considered. When bright and

j. c. rathbun is professor of pediatrics at the Uni-
versity of Western Ontario and pliysicmn-in-chief of
The War Memorial Children’s Hospital, London,
Ontario.

Presented to the Canadian Medical Association,
June 20, 1957, at Edmonton, Canada.

dark red blood is mixed, the causes usually stem
from disorders higher in the gastrointestinal
tract, which are shown in column 3. Black and
tarry blood, due to the action of hydrochloric-
acid which produces acid hematin, is usually
the result of lesions in the upper gastrointestinal
tract or above, which are shown in column 4.

There are several substances which can be
confused with blood and, on occasion, cause dif-
ficulty. These are shown in column 5. Parents
often mistake blood in the stool for the red color
produced by various drugs, such as Achromycin.
One of our recent cases of intussusception was
not seen for thirty-six hours because the parents
mistook blood and mucus for the Achromycin
the child was taking by mouth. Beets are a well-
known offender, and uric acid leaves a pink stain
on the diaper which may mislead the unwary.

This discussion will be limited to the first and
most important group, that in which bright red
blood is passed by bowel. However, it must be
remembered that the stool findings depend on
the state of motility of the bowel as well as the
size of the hemorrhage. Thus, any of the condi-
tions outlined in the third and fourth columns
can produce bright red blood in the stool if
bowel motility is increased and the hemorrhage
is fairly large.

In approaching this problem, the first consid-
eration is the frequency with which these out-
lined causes occur. Table 2 indicates the relative
incidence in hospital practice of the various con-
ditions which may cause bright red rectal bleed-
ing. These figures represent the incidence over
a five-year period of the causes seen in column
1 of table 1. The difference between hospital
experience and office practice is striking.

The most frequent and serious cause of blood
in the stool is intussusception. This condition
must be excluded at once in any case of rectal
bleeding, for a missed diagnosis in such instances
may be fatal. This is the group in which many of
our diagnostic difficulties arise. Classically, in-
tussusception occurs primarily between the ages
of 5 and 7 months in a well child. The onset
is usually characteristic, with sudden, violent,
crampy pain and vomiting unassociated with
diarrhea but accompanied by progressive shock.

86

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TABLE 1

CAUSES OK RECTAL BLEEDING

■■ ■-- - - - A-

Common

Rare

Mixed blood

Black

Common errors

Intussusception

Foreign body

Purpura

Nosebleed

Drugs — Achromycin

Leukemia

Hemorrhoid

Trauma

Peptic ulcer

Foods — beets

,\ 1 cckel’s divert iculu m

Purpura

Peptic ulcer

Violent vomiting

Uric acid

Fissure-in-ano

Hemophilia

Typhoid

Esophageal varices

Rectal polyp

Mesenteric I hrombosis

Nursing blood

1 lemophilia

Hemorrhagic disease

Erythroblastosis fetalis

1 lemophilia

Purpura

Volvulus

Obstructive jaundice

Neoplasm

Trauma

Dysentery
Nursing blood

Neoplasm

Hemorrhagic disease
Colitis

I lemorrhagic disease
Nursing blood
Tonsillectomy
Duplication of bowel

TABLE 2

the stool.

It is imperative to

diagnose intussus-

CAUSES OF RECTAL BLEEDING
CHILDREN’S HOSPITAL. 1951-1955

Intussusception

26

Leukemia

17

Meckel’s diverticulum

13

Fissure-in-ano

12

Rectal polyp

9

Hemorrhagic disease

6

Volvulus

5

Dysentery

i

89

ception within twenty-four hours after the onset
if resection of necrotic bowel is to be avoided.

Kiesewetter and associates1 recently pointed
out the importance of chronic recurrent sigmoid
intussusception. In the case of a dolichocolon,
the redundant sigmoid may readily telescope
down into the lower bowel when the child
strains. This has been revealed by sigmoidosco-
py. The leading edge may then bleed and pro-
duce melena.

Treatment is tending to revert to medical

These symptoms should suggest the diagnosis
before the appearance of the typical bloody, cur-
rant jelly stools. A palpable, sausage-shaped,
doughy tumor may be felt in the right upper
quadrant, and blood is obtained on rectal ex-
amination. With increasing clinical awareness,
only about half of our cases have bloody stools
when they are first seen.

Diagnosis may be confirmed by barium enema
with the results shown in figure 1, which shows
clearly the “coiled spring” appearance of the in-
tussusception. Our greatest difficulty has been
with ileoileal intussusception in which a charac-
teristic story is given, but no mass is palpable
and no blood is passed by rectum. This condi-
tion must be diagnosed by a flat plate of the
abdomen showing small bowel obstruction with
fluid levels when the child is held upright as
seen in figure 2. This should be followed by
barium enema. The commoner ileocecal type
and the rare colicocolic type cause less diagnos-
tic difficulty because blood appears earlier in

mm wmmm

Fig. 1 . Intussusception showing “coiled spring” appear-

MARGH 1958

87

Fig. 2. Flat plate of abdomen showing small bowel ob-
struction with fluid levels.

management by barium enema reduction. This
reflects the management of over one hundred
years ago,2 and, in careful hands with conserva-
tive management, 50 per cent of cases can be
satisfactorily reduced.3 However, if reduction
fails or if a second intussusception occurs, sur-
gical intervention is essential. Since about 10
per cent of cases have a Meckel’s diverticulum,
lymph gland, polyp, or tumor of the bowel which
precipitates the bowel intrusion, an operation is
necessary to remove the cause. Many small bowel
lesions are difficult to demonstrate clinically, and
a laparotomy may be the only successful method.
Even with surgical exploration, some cases recur
two or three times without explanation.

Leukemia usually bleeds late in its course
when other signs and symptoms make the differ-
entiation easy. This error can be avoided with
a routine blood count. Similarly, the various clot-
ting and nutritional disturbances usually produce
other signs and symptoms.

Meckel’s diverticulum or omphalomesenteric
duct with hemorrhage is a clinical diagnosis.
These cases present with either bright or dark
red, massive, painless bowel hemorrhage, with
clots and no other findings. The Meckel’s diverti-
colum is difficult, if not impossible, to demon-
strate by x-ray with contrast media, and only one
or two have been demonstrated in Victoria Hos-

pital, London, Ontario, in the past ten years. A
laparotomy is performed in these cases only
after a second occurrence of bleeding unless the
initial hemorrhage has been extreme. This pre-
vents unnecessary operation, for it is well accept-
ed that small bowel lesions are practically un-
detectable, and many other causes may be con-
fused with a hemorrhaging Meckel’s diverticu-
lum. For example, reduplication of bowel, which
also has gastric mucosal rests in it, is not in-
frequently mistaken for Meckel’s diverticulum.
The management is the same — laparotomy. In
all cases, the patient is transfused preoperatively
as blood loss may be considerable.

Fissure-in-ano is the commonest cause of
bleeding in infancy that is encountered in office
practice. A hard stool produces a fissure and a
blood-streaked stool in an infant. These fissures,
in contradistinction to adults, are readily healed
by keeping the stools soft with a mild laxative
and the fissure clean by washing, followed with
an antibiotic ointment containing tyrothricin,
bacitracin, or other nonabsorbable antibiotics.
On this routine, the fissure usually heals in about
one to two months. The radical surgery used in
adults is not necessary and is contraindicated.

Rectal polyp, the fifth cause of bleeding in
hospital patients, is accepted as the commonest
cause of massive rectal bleeding among patients
in office practice. Blood is passed often after a
stool. Diagnosis is easily made by doing a rectal
examination, when most of these tumors are pal-
pable within 1 in. of the anal orifice as a rounded
mass the size of a pea. These are mucosal polyps
and are often pedunculated. The remainder can
be readily visualized by proctoscope and re-
moved by fulgurization. Occasionally, these tu-
mors develop at the anus as shown in figure 3.

Fig. 3. A polyp which developed at the anus.

88

THE JOURNAL-LANCET

Furthermore, polyps are sometimes multiple
in quantity and distributed throughout the colon.
These cases of multiple polyposis are familial in
nature and usually have a more fibrous center
which gives them a different gross appearance.
These are frequently associated with pigmenta-
tion of lips.4 5 Coller11 has pointed out that these
lesions invariably become malignant, and he
recommends early colectomy. This procedure
should not be undertaken until the polyps have
been confirmed by two successive barium ene-
mas in order to be sure they are not fecal balls.

Hemorrhagic disease of the newborn is the
most common cause of bleeding in this period.
It usually occurs on the third or fourth day post-
partum and is accompanied by bleeding from
the navel, vagina, kidney, nose, or by the vom-
iting of blood. Diagnosis can be made by clot-
ting time and prothrombin time estimations.
This condition is treated by the administration
of fresh blood and vitamin K. Our English col-
leagues7 recently pointed out the danger of
hemolysis that an excess amount of vitamin K
may produce. They suggest that only 2 mg. be
given and repeated once if necessary.

Hemorrhagic disease of the newborn must not
be confused with nursing blood or swallowed
blood. Apt* has shown that 35 to 40 cc. of blood
swallowed by an infant appears bright red in
the stool in nine to thirty hours. The presence
of this maternal blood can be determined by
taking 1 cc. of blood and diluting it to 5 cc. with
distilled water. To 5 cc. of this solution, 1 cc.
0.25 NNaOH is added. Maternal blood turns
brown, while fetal blood turns pink.

Volvulus and mesenteric thrombosis are in-
frequent causes of rectal bleeding but must be
considered in young infants with small bowel
obstructions. The frequent congenital defects
which come to light in this age group are usually
the precipitating factors, such as malrotation of
the gut and persistent omphalomesenteric duct.
Characteristically, these babies present with tre-
mendous abdominal distention, vomiting, crampy
abdominal pain with tinkling bowel sounds,
blood and mucus in one stool, and then no stools
thereafter. A roentgenogram reveals signs of
small bowel obstruction, and the treatment is,
of course, surgical.

Dysentery is a more frequent cause of blood
in the stool than the figures indicate. The diag-
nosis is usually not difficult, for the child has
diarrhea with blood flecking or small drops of
blood in the stool. This arises from ulceration
of the small or large bowel. Culture of the stool
reveals, in most cases, a member of the Salmo-
nella group. Treatment with a broad-spectrum

Fig. 4. Photograph shows multiple purpuric spots in a
child with Henoch’s purpura.

antibiotic usually controls this infection. Chronic
ulcerative colitis produces similar stools.

Two of the rarer causes of rectal bleeding
which appeared in this series were Henoch’s
purpura and rectal prolapse. The purpura fol-
lowed two weeks after an upper respiratory in-
fection. This child presented with multiple pur-
puric spots ( figure 4 ), and then bloody mucus ap-
peared in her stools which resembled intussuscep-
tion, as crampy abdominal pain accompanied it.

The second patient had severe prolapse of the
rectum following malnutrition. This condition
is usually accompanied by bright red rectal
streaking, and, of course, the diagnosis is obvi-
ous (figure 5). Treatment consists of restoring

an”*

Fig. 5. Patient with severe prolapse of the rectum.

MARCH 1958

89

nutrition, strapping the buttocks, and adminis-
tration ot a sufficient amount of laxative to keep
stools soft. Rarely, sclerosing solutions or sur-
gical suspension are necessary.

In conclusion, a review of the various causes
of rectal bleeding shows a considerable differ-
ence in the frequency of the types of cases seen
in office and hospital practice. In the former,
anal fissure and rectal polyps are the usual
causes, while intussusception and Meckel’s di-
verticulum are the important types seen most
often in the hospital. It is because of the last
two conditions that no case of rectal bleeding
should be ignored, as both may be fatal or at

REFERENCES

1. Kiesewetter, W. B., Cancelmo, R., and Koop, C. E.:
Rectal bleeding in infants and children. J. Pediat. 47:660,
1955.

2. Meigs, J. F., and Pepper, W.: Diseases of Children. Phila-
delphia: P. Blakiston, Son & Co., 1886. p. 494.

3. Childe, A.: Annual meeting, Canad. Paediat. Soc., Winni-

peg, 1957.

4. Behrer, M. R.: Jejunal polyposis with intussusception and

melanin spots. J. Pediat. 38:641, 1951.

least produce serious stigmata for the rest of the
patient s life after bowel resection.

The difficulty of diagnosing ileoileal intussus-
ception has been stressed, and a high index of
suspicion must be maintained if errors in diag-
nosis are to be avoided. The diagnosis of intus-
susception during an epidemic of gastroenteritis
is extremely hazardous.

A careful and detailed history and physical,
rectal, and proctoscopic examinations with roent-
genograms, where indicated, help to prevent
tragedy in eases of rectal bleeding. Clinical
judgment in these cases may be taxed to the
limit.

5. Baffes, T. G., and Potts, W. J.: Blood in stools of infants
and children. Pediat. Clin. North America 2:513, 1955.

6. Coller, F. A.: Cancer of Colon and Rectum. Am. Cancer
Soc., Inc., monograph, 1956, p. 94.

7. Crosse, V. M., Meyer, T. C., and Gerrard, J. W.: Kemic-
terus and Prematurity. Arch. Dis. Childhood 30:501, 1955.

8. Apt, L., and Downey, W. S., Jr.: Melena neonatorum;

swallowed blood syndrome. J. Pediat. 47:6, 1955.

Eighty per cent of premature infants pass their first stool within twenty-four
hours after birth and 94 per cent within forty-eight hours. In comparison, 94
per cent of normal full-term infants pass the first stool within twenty-four hours.

Meconium retention in the newborn period suggests intestinal obstruction.
Delayed or infrequent passage of meconium, with or without signs of intestinal
obstruction, may be the first sign of Hirschsprung’s disease.

Stimulation of the rectum with a thermometer or an enema of 10 to 15 cc.
of normal saline may result in free passage of meconium. If not, and if other
symptoms develop or a stool is not passed within the next twelve hours, the
abdomen should be examined by roentgenograms for distended loops of bowel.
If no abnormalities are seen, sterile water feedings may be instituted and th('
infant watched closelv until a stool is passed.

All premature infants who have not voided bv twentv-four hours should be
observed carefully . If the external genitalia show no obvious abnormalities and
the kidneys do not appear enlarged bv palpation, the general condition of the
infant determines further diagnostic measures.

Irving Kkamer, M.D., and S. Norman Sherry, M.D., Sinai Hospital, Baltimore. J. Pediat. 51:
.373-376, 1957.

90

THE JOURNAL-LANCET

Office Gynecology

EDWARD A. BANNER, M.D.
Rochester, Minnesota

Though patients with gynecologic disabili-
ties comprise a large part of general prac-
tice, most medical school curricula and hospital
teaching programs are so filled that there is in-
sufficient time to stress office procedures in gyne-
cology. The material that I shall present is based
on personal observations and experiences with
practicality in mind.

Much may he learned from casual observation
of the gynecologic patient as she walks into the
office that may aid in diagnosis. Obtaining a his-
tory is still a great art. Diagnoses are often sug-
gested by the history and may be missed if the
physician is not a good listener. In many in-
stances, a complete physical examination is re-
quired. This examination may reveal systemic
causes for the gynecologic symptoms or extra-
gynecologic lesions with symptoms that might
be incorrectly interpreted to be of gynecologic
origin.

The conditions to which the gynecologist’s at-
tention is called most often include inflammatory
and infectious diseases, new growths, sequelae
of labor, and endocrine dysfunctions that pro-
duce aberrations of menstruation. The patient
often seeks counsel because of abnormal vaginal
secretions, genital bleeding, or pelvic pain. Less
often she may come because of protruding
masses or generalized pelvic or abdominal dis-
comfort. Still others may visit the office because
of the persistent “cancer drives,” which make
them apprehensive and desirous of reassurance
from the physician.

Whatever the cause, the number of such pa-
tients in the office of the gynecologist is increas-
ing, for most clinics report that more and more
patients go to the “office” gynecologist rather
than to the “surgical” gynecologist. The net
result is to place greater responsibility on the
physician, for, if mass education sends more
patients to him, he will be expected to detect

edward a. banner is a consultant in the Section of
Obstetrics and Gynecology at the Mayo Clinic and
is assistant professor of obstetrics in the Mayo Foun-
dation.

Read at the meeting of the Southwestern Medical
Association, El Paso, Texas, October 9 to 11, 1957.

processes in earlier stages when treatment can
be swift and effective and lives can be saved.

HISTORY

Much can be learned from an adequately taken
history, which often reveals significant illnesses
or symptoms that are otherwise missed. Many
patients who come to the office with gynecologic
complaints have no demonstrable organic dis-
ease. Often, they are merely indicating anxiety,
fear, resentment, or guilt. The practical gyne-
cologist must be a physician well skilled in the
practice of gynecology and also a practical
psychologist. He must integrate into his diag-
noses the personality of the individual in order
to treat her ailments properly. The following
word of caution perhaps should be introduced
here: the diagnosis of functional illness must be
established not only by exclusion of organic dis-
ease but also on the basis of its own characteris-
tics as well. Certain diseases can be treated by
psychologic advice, but it is also possible to treat
a neurotic individual incorrectly by physical
measures. The best way to avoid improper, un-
necessary, or even harmful treatment is to be
sure of the diagnosis.

The medical history should provide pertinent
information about the patient’s family, her social
background, occupation, sexual habits, marital
problems, and so forth. Occasionally, the physi-
cian must be rather obtuse in exploring personal
problems with the patient, for, if approached too
directly, she may set up an antagonistic defensive
attitude and obstruct further enlightening dis-
cussion. A distinguishing characteristic of the
competent clinician is his ability to sense intui-
tively that which the patient is trying to express
and to let her vent her feelings in such a manner
that she will not be offended by apparent accusa-
tions. In gynecology more than any other speci-
alty, the combination of disease with sexual prob-
lems requires an understanding of the psychology
that was developed many years before.

PHYSICAL EXAMINATION

A general physical examination should follow the
history and should, whenever possible, precede
the pelvic examination.

MARCH 1958

91

What to look for. In the general examination
of the patient, much can be learned at a glance
about her habitus and whether she has masculine
or feminine characteristics, is robust or frail,
hirsute or balding. The temperature, pulse rate,
and blood pressure should be recorded. The
breasts should be examined, for, as secondary
sex characters, they share in many changes and
physiologic conditions within the pelvis.

In the abdominal examination, the physician
should note the presence or absence of striae
indicative of rapid loss of weight and evidence
of past pregnancies or endocrine dysfunction.
Tender areas should be carefully palpated, and
distinction should be made between rigidity and
normal muscular defense reaction. Although an
adequate abdominal examination is neglected by
many, it actually may bring to the fore the pri-
mary difficulty at hand, especially if the patient
is acutely ill or apprehensive. Incidentally, a
full bladder has, at times, deceived the shrewdest
of examiners. For this reason, some gynecologists
have the patient void immediately before ex-
amination to forestall such a diagnostic pitfall.

Pelvic examination. Whatever is learned after
the history and the physical examination must be
gained tactually and correlated with information
gained from both these procedures. To develop
the tactile sense, one should do enough pelvic
examinations to acquire the faculty of instant
recognition not only of the normal anatomic re-
lationship but also the minor aberrations that are
the hallmarks of pelvic disease. One should be-
come familiar with the nodular, tender areas in-
volving the uterosacral ligaments and posterior
uterine surface, so characteristic of endometrio-
sis, and also with the thickened, tender, and bul-
bous swelling of the tubes portraying the after-
math of pelvic inflammatory disease.

Equipment. All the necessary equipment for
the proper performance of a pelvic examination
should be at hand before the examination is be-
gun. This includes drapes, hand protection, lu-
bricants, light, material for taking smears, and a
table that offers the examiner every advantage.

Since the speculum is an indispensable instru-
ment to the gynecologist, a word shoidd be said
regarding the various types available. For most
purposes, the bivalve speculum is satisfactory.
It is made in several sizes, and the examiner
selects the size that can be introduced easily and
does not cause the patient discomfort. In child-
ren, the most satisfactory speculum is the tubular
cystoscope, which is used with the patient in the
knee-chest position. The tubular speculum is
available in various sizes. For some patients, the
flat Sims speculum may be used to advantage.

Rapprochment with patient. Establishing the
patient’s confidence is the greatest single factor
in promoting ease of examination. Unconsidered
remarks or chance actions that engender fear,
resentment, or anxiey may result in a tense, dis-
turbed, or apprehensive patient. Such a patient
is rigid and ill at ease and in a state that may
make pelvic examination impossible or seriously
unproductive. In creating confidence, gentleness
is the first essential. Relaxation may be encour-
aged by asking the patient to breathe through
her mouth. Constant reassurance is helpful. No
violation of modesty shoidd enter the pelvic ex-
amination, but exposure should be consistent
with thoroughness. The presence of a nurse or
an assistant may aid in this respect. Most of all.
the physician should maintain an attitude of
kindly and impersonal thoroughness. A pelvic
examination is not a pleasant experience for any
woman, and the success with which it is con-
ducted depends as much on the attitude of the
physician and his assistant as on the actual sit-
uation in the pelvic region.

What to look for. Inspection of the external
genitalia is done with the patient in the lithotomy
position and with the physician standing be-
tween the patient’s knees. The vulva is inspected
for dermal lesions, excessive secretions, and mas-
ses. Since vulvar neoplasms frequently metasta-
size to the inguinal lymph nodes, these nodes
shoidd be palpated for tenderness or enlarge-
ment. Small, shotty inguinal nodes are not un-
usual, especially in young women, and should
cause no concern unless they are associated with
definite lesions.

After examination of the vulva, the labia
should be gently parted, and the size, shape, and
dermal changes, if present, shoidd be noted care-
fully. Inspection for kraurosis vulvae, lichen
sclerosus et atrophicus, and leukoplakia should
be made. Normally, Bartholin’s glands shoidd
not be palpable, and Skene’s glands should not
be tender. If the hymen is intact, examination
of the pelvic organs may be completed recto-
abdominally. Careful note should be made of
the caliber of the introitus. By pressure exerted
downward against the perineal bodv during
vaginal examination, more space may be ob-
tained with less discomfort to the patient.

The condition of the pelvic floor is then deter-
mined. To ascertain the presence or absence of
rectocele is not difficult but may be rendered
easier by pressure exerted upward on the pos-
terior vaginal wall through the rectum. The size,
shape, consistency, and position of the cervix
shoidd then be determined by palpation. A nor-
mal cervix is said to have the consistency of the

92

THE JOURNAL-LANCET

end of the nose, whereas a cervix invaded by a
malignant process generally has a hard or grittv
consistency.

At this point, examination with the speculum
is begun. It is well to recall that the axis of the
vagina is directed posteriorly, while the long axis
of the introitus is anteroposterior. It is desirable
to introduce the bivalve type of speculum, with
its transverse axis vertical to conform to the
shape of the vaginal orifice. This is preceded by
separating the vulva and applying pressure on
the perineal body. When it is well past the en-
trance of the vagina, the speculum is turned so
that the blades lie transversely, with the tip of
the speculum pointed posteriorly toward the
vaginal floor when the blades are opened. The
common practice of using soap or lubricants is
not advisable, since soap alters the chemical
reaction of the vaginal secretions and interferes
with staining and cultural reactions. Lubricants
also frequently make interpretation of Papani-
colaou stains for malignant cells more difficult
or even impossible. Rather, it is better to wet the
gloved hand and speculum with warm water,
thereby decreasing the shock to the patient and
offering adequate lubrication.

With the aid of a strong light, the cervix is now
visualized directlv. Its size, position, and length,
as well as the nature of its secretions, are noted.
This is the moment at which an old adage be-
comes most significant: “Examine the cervix with
a strong light and with a suspicious mind.” A
smear for study by the Papanicolaou technic may
be taken. Secretion should be taken from both
the internal os and the vaginal pool. Samples
may be obtained with either a wooden spatula
or a cotton applicator. The secretion is spread
on a clean glass slide which is dropped immedi-
ately into a solution of 95 per cent alcohol. Be-
cause of the danger of explosion, ether should not
be added to the solution of alcohol stored about
the office.

Next, the cervix is inspected for evidence of
cystic change, lacerations, or erosions. A speci-
men of any abnormal tissue that is seen should
be taken for biopsy before definitive therapy is
offered. Such a specimen should always be ob-
tained if cervical erosions are present, and care
should be exercised to secure adequate tissue
from the squamocolunmar junction. This should
be done before cervical cauterv is attempted.
The application of Lugol's solution will demar-
cate those areas most applicable for biopsy.

Normal cervical and vaginal epithelium con-
tains glycogen, whereas abnormal epithelium,
such as that found in erosions or a malignant
lesion, contains little or none at all. Hence, by

applying a weak solution of iodine (one-fourth
strength tincture of iodine) to these areas, a
marked differentiation may be obtained rapidly.
Normal tissue becomes a deep mahogany brown
and the pathologic surface turns pink. Speci-
mens for biopsy should be taken from the pink
or light areas. One must be cognizant of the fact
that the Schiller or iodine test is not specific for
any type of lesion, nor does it distinguish malig-
nant from benign tissue. It merely demarcates
the areas from which specimens of tissue for bi-
opsy should be taken. There is no special time
in the menstrual cycle when the specimen for
biopsy should be obtained. In this regard, the
endocervix should not be neglected, because the
introduction of a small sound or cotton applicator
within the cervical canal ( the so-called Clark
test) often discloses a pathologic process that
otherwise might have been missed.

Many women present with bleeding after sub-
total hysterectomy. Under such circumstances, a
small endocervical curet may be used to obtain
tissue for examination. If small endocervical
polyps are the cause of the bleeding, this curet-
tage may be therapeutic as well as diagnostic. It
is always well to submit all such material to a
competent pathologist for careful examination
and evaluation.

It is also a wise practice to remove all polyps
that may be found extruding from the cervix.
Polyps can be removed easily by torsion. This
procedure should be followed by fulguration of
their bases. All polyps should be examined by
a competent pathologist. Before the speculum
is removed, the condition of the vaginal walls
should be observed, with attention given to the
presence or absence of excoriations or new
growths.

The bimanual examination, which would better
be known as the “vaginal-abdominal examina-
tion,” can be made with fingers of either hand
within the vagina. From a practical standpoint,
especially if tbe physician practices obstetrics, it
is useful to develop ambidexterity in this per-
formance. With the examiner’s fingers resting
against the pelvic floor, the cervix is palpated,
while the examiner’s other hand is placed flat on
the lower part of the patient’s abdomen. By
elevating the palm and using the tactile sense in
the balls of the fingers rather than in the tips, the
various organs are located, steadied, and evalu-
ated. The size, shape, and consistency of each
structure can be determined, and, if tumors pro-
ject into the superior strait, their outlines can be
noted.

.After the cervix has been palpated, the pres-
ence or absence of pelvic pain on motion is de-

MARCH 1958

93

termined. The position of the uterus is ascer-
tained by locating the body of the organ. When
the uterine fundus lies in its normal relationship,
it is usually in an anteflexed position. Retroces-
sion or retroflexion occurs normally in a high per-
centage of women. The mobility of the uterus
may then be thoroughly tested. Immobility or
excessive pain on uterine motion may be indica-
tive of chronic infection, acute exacerbation of
chronic infection, adhesions, or endometriosis.
When the median part of the pelvis has been
palpated and the condition of the uterus has
been determined, the examining fingers are now
slid into one of the fornices lateral to the uterus.
The abdominal hand is directed in a like plane
and is moved slowly and deliberately.

Next, the examiner’s fingers in the vagina are
pushed out into the lateral fornix, while the hand
resting on the abdomen is directed in a like
plane. The ovary is then palpated between the
tips of the fingers of both hands. A normal ovary
is sensitive and mobile. Ovaries that are retro-
cessed within the pelvis are best examined later
bv the recto-abdominal approach. The physician
should become familiar with the normal size of
an ovary and should keep in mind its tendency
to enlarge after contralateral oophorectomy and
hysterectomy. The normal ovary feels like an al-
mond; it is about 4 cm. long and 2 to 3 cm. wide.
Normally, it moves within a limited range.
Occasionally, its mobility may become abnormal
and it may be situated immediately lateral to the
cervix, within the cul-de-sac, or high on the lat-
eral pelvic wall.

Normal fallopian tubes usually cannot be pal-
pated through the vagina. However, if they are
thickened or are the sites of chronic residual
changes from infection, they may be sensed as
masses of hornlike shape which occasionally are
fluctuant and many times are tender, firm, and
resistant.

Rectal examination should be done for all
patients who complain of difficulties referable
to the pelvis, and it is especially indicated for
young women with an intact hymen. When a
pelvic malignant process is present, the recto-
abdominal examination gives, perhaps, more in-
formation than any other. The necessity for an
empty bowel is clear. Care should be taken not
to exert too much pressure against the anterior
wall of the bowel, for that structure may be ex-
tremely tender. Should abnormalities be noted,
proctoscopic examination is indicated.

Lesions within the vagina and cervix occasion-
ally may be seen best by examining the patient
in the knee-chest position. The vagina is easily
distended with air, making the vaginal rugae

disappear and allowing the walls of the vagina
to be seen clearly. Children and young girls are
best examined in this position and with the aid
of a Kelly cystoscope.

At times, it may be necessary to anesthetize the
patient in order to carry out pelvic examination.
An anesthetic is indicated only after repeated
pelvic examinations have been entirely unsuc-
cessful, sometimes with several days intervening.
One should be aware not only of the usefulness
of this procedure but also of its limitations.
Naturally, examination of the pelvis with the
patient under anesthesia has no value when the
cooperation of the patient is needed; for example,
to locate sites of pain or minimal discomfort. In
general, the more nearly complete and the more
accurate the pelvic examination is, the less fre-
quent is the need to resort to anesthesia in diag-
nosis.

VAGINITIS AND LEUKORRHEA

The conditions treated most often by the gyne-
cologist in his office are vaginitis and leukorrhea.
The word “leukorrhea” actually refers to any
vaginal discharge. Usually, however, it implies
an abnormal vaginal discharge. The most com-
mon types are Trichomonas vaginitis, Monilia
vaginitis, nonspecific or Hemophilus vaginitis,
and senile vaginitis.

Trichomonas vaginitis. This type of infection
is found in all age groups and frequently occurs
during pregnancy. In 20 to 25 per cent of the
average gynecologic practice, it may be found
easilv and may be entirely asymptomatic. Actu-
ally, the causative agent is a stubborn proto-
zoan invader with a characteristic large body
about twice the size of a white blood cell. When
viewed under high power, granules are seen
within the cytoplasm and several flagella which
whip around to make the parasite motile.

The clinical picture of Trichomonas vaginitis
is characteristic. The mucosa of the vagina us-
ually appears reddened and, when the condition
is severe, presents an over-all red with straw-
berry patches. The color of the vagina, of course,
depends upon the extent and severity of the in-
fection. Usually, the infection is accompanied
by a profuse, light-yellow discharge in which air
bubbles are often entrapped, giving a character-
istic frothy or bubbly appearance. The common-
est subjective symptoms are vaginal discharge
with itching and soreness and, not infrequently,
dvspareunia. Frequently, the patient states that
the condition became exaggerated after her men-
strual period.

The diagnosis of Trichomonas vaginitis is
made by examining a small amount of the dis-

94

THE JOURNAL-LANCET

charge on a plain glass slide to which may be
added a few drops of physiologic saline solution
and a coverslip. Under the microscope, an area
showing evidence of movement is found under
the low-power objective. The high power is
then adjusted, and the motile organisms are read-
ily discernible. If the light is subdued under the
stage, the flagella may be noted whipping about
nervously, and the amebalike pseudopods are ob-
served when the trichomonads change in shape
and size. The only other vaginal invaders that
may confuse the picture are spermatozoa, but,
if one has had the opportunity to compare them
with the former at least once, the diagnosis will
never be confused.

The treatment of Trichomonas vaginitis actu-
ally should be along three lines. The first is pre-
ventive, consisting of prophylactic measures. The
patient should be taught the importance of wash-
ing her hands after a bowel movement and also
before inserting vaginal tampons during menstru-
ation. She should be instructed to wipe back-
ward with toilet paper after defecation and not
to employ the enema tip for vaginal douching.
The basic aim of the second line of treatment is
to restore and maintain the vaginal pH between
4.5 and 5 and to treat the patient during her
menstrual period. Good results have been re-
ported with many types of medication. My
colleagues and I prefer initially to insufflate the
vagina with a preparation of acetarsone ( powdex
Stovarsol compound). Each single-dose cart-
ridge contains 7 'A gr. of acetarsone. This drug is
stabilized with a soothing nonirritating diluent of
zinc oxide and salicylic acid compound. Besides
restoring the proper pH of the vagina, the prep-
aration has the added advantage of being hy-
droscopic. Even the most moist vagina and vulva
will be dry the first night after it is used, and this
in itself has a great psychologic advantage for
the subsequent treatment that may be used. We
install the first powdex treatment with the patient
in the knee-chest position and generally use 2
single-dose cartridges for this treatment. We
give the subsequent 5 daily doses with the pa-
tient in the usual lithotomy position without in-
terruption between doses for douches or other
medication. Sexual congress should be discontin-
ued until the condition is improved. In pregnant
patients, a speculum is employed during insuffla-
tion to prevent possible air embolism. Following
treatment with this compound, the patient is in-
structed in the use of vaginal suppositories, con-
sisting of a preparation of diodoquin ( Flora-
quin). Upon completion of this form of therapy,
she is re-examined after 3 menstrual periods. No
method that I know is 100 per cent successful.

Monilia vaginitis. Mycotic vaginitis is a com-
mon cause of leukorrhea. It is found most fre-
quently during pregnancy, in diabetic patients,
and in patients recently treated with broad-
spectrum antibiotics. Although other types of
yeast may produce vaginitis, Monilia, such as
Candida albicans, has been the most frequent
invader. The vagina may be covered by whitish
to grayish plaques that are adherent to the vagi-
nal wall. The most common symptoms are itch-
ing, burning, vaginismus, dyspareunia, and, oc-
casionally, frequency and urgency of urination.

The diagnosis is made in a manner similar to
that in which Trichomonas vaginitis is diagnosed.
A small portion of the discharge is placed on a
slide with a drop or two of saline solution. In
this, bamboo-like structures are found with seg-
ments, granules, and budding. Special strains
are not necessary for the diagnosis. Often, tricho-
monads, as well as Monilia organisms, are found
in the same smear.

Monilia infections most frequently respond to
the use of nystatin ( Mycostatin ) vaginal suppos-
itories. One of these is placed in the vagina in
the morning and one at night for twelve days.
Douches are not used during this period.

Nonspecific or Hemophilus vaginitis. The third
tvpe of vaginitis, which up to now has been
called “nonspecific," probably is Hemophilus
vaginitis, first reported by Leopold. The symp-
toms are less pronounced than in other tvpes
and seldom consist of more than moderate itch-
ing and burning. The leukorrhea resembles that
of trichomoniasis but usually is gray in contrast
to the yellow or white of trichomoniasis. There
is a close correlation between Hemophilus vagi-
nalis and epithelial cells with indefinite outlines
and coarsely granular cytoplasm, as seen in wet
preparations. These cells have been labeled
“clue cells” and are considered practically diag-
nostic, though a similar cell is occasionally seen
in vaginitis from other causes. A gram-stained
smear of the discharge shows large numbers ol
the typical gram-negative pleomorphic bacilli.
This organism resists culture, the most satisfac-
tory medium to date being modified sheep’s
blood agar incubated in an atmosphere of in-
creased carbon dioxide.

Treatment consists of local applications of a
vaginal cream of triple sulfonamides or, more
recently, a preparation of hexetidine ( Sterisil
vaginal sol). For Hemophilus infection of the
male urethra, treatment with one of the tetracy-
cline group of antibiotics has been suggested.
Sterisil vaginal sol has been offered as a general
therapeutic agent in the treatment of not only
Hemophilus vaginitis but also Trichomonas and

MARCH 1958

95

Candida vaginitis. Initially, research interest was
aroused in these compounds when it was demon-
strated that they inhibit glycolysis and also ad-
sorb on protein materials. Subsequent studies
demonstrated that this series of compounds has
an antibacterial spectrum similar to that of the
broad-spectrum antibiotics. This drug has been
found to be safe during pregnancy and for in-
fants and children.

Senile vaginitis. This type of vaginitis usually
occurs after the menopause but is occasionally
seen after surgical treatment, irradiation, or path-
ologic destruction of the ovaries. These patients
may complain of discharge, burning, dyspareunia
or, occasionally, a bloody, serosanguineous leu-
korrhea. The etiology rests in the loss of estro-
genic hormone with resultant atrophy and thin-
ning of the vaginal mucosa. Loss of the protec-
tive layers of the vaginal epithelium leads to
drvness and often to the formation of adhesive
bands within the vagina. Inspection reveals that
the mucosa is thin and atrophied and contains
numerous areas that bleed easilv on palpation.
The entire vaginal orifice actually may be scarred
down to one half of its normal size.

Treatment includes the use of vaginal supposi-
tories containing 0.5 to 1 mg. of stilbestrol each,
to be inserted nightly for two to four weeks be-
fore retiring. A cream of conjugated estrogenic**
substances (Premarin) has also been found effec-
tive.

NEW GROWTHS

New growths cannot be dissociated from cervi-
citis due to the various forms of vaginitis pre-
viously' described and from cervical erosions as-
sociated with cervical changes of a benign na-
ture, for, as Novak has said, despite statements in
the textbooks, it is difficult to diagnose cancer
from the gross appearance of the cervix. Some
of the worst looking cervical lesions have proved
to be benign, while others, appearing rather in-
nocuous, have proved to be manifestations of
early cancer. The moral, of course, is to take
smears or biopsv specimens if there is even the
slightest doubt, and one may paraphrase the
statement by saying that ideally every female
patient should have a Papanicolaou smear. If
cancer is suspected clinically, however, even
with negative cytologic findings, the condition
should be investigated along traditional lines.
At least 1 case in 150 of uterine cancer that
would escape the most careful scrutiny in routine
outpatient practice can be detected by the smear
technic. Furthermore, this technic can be done
in the earliest stage of the disease, when a very
high percentage of permanent cures can be justi-

fiably expected. The need for advocating earlv
diagnosis bv balanced and efficient teamwork
scarcely requires further emphasis. The method
of collecting and fixing smears is simple enough
to be suitable for use in the practitioner’s office.
The cytologic method plays a valuable role in
raising suspicion of malignant processes and in
encouraging close surveillance of the gynecologic
patient with atypical cervical epithelium. Should
this procedure become a routine in the office of
every practicing physician, there is no telling
what the over-all outcome would be, just as the
ultimate favorable outcome of Papanicolaou’s
original work of forty years ago, which was con-
cerned with the exfoliation of cells into the
vagina of rodents, was unpredictable.

chronic: cervicitis

Since every case of chronic cervicitis is potential-
ly a case of carcinoma of the cervix, early malig-
nant disease of the cervix must be excluded first.
As indicated previously, many benign-appear-
ing cervical lesions may harbor preeancerous
changes. Should the Papanicolaou stain or smear
and biopsy or conization prove that the chronic
cervicitis is actually a benign condition, the cer-
vix should be cauterized or treated otherwise.
Electrocauterization or other methods of tissue
destruction by heat applied immediately after
biopsy may bring about changes in the tissue so
that a repeat biopsy may be misleading. When
the results of biopsy are negative but the lesion
still appears suspicious, another biopsy specimen
should be taken because the original specimen
may not have been chosen from the proper site
to show malignant change. Rather than use a
cautery to stop the small bleeding points created
by biopsy, my colleagues and I apply oxidized
cellulose ( Oxycel ) or absorbable gelatin sponge
( Gelfoam ) plus an iodoform pack, which con-
trols bleeding in almost all instances. When bi-
opsy discloses chronic endocervicitis or cvstic
cervicitis, with no evidence of malignant change,
then and only then do we proceed with treat-
ment.

The active treatment of cervicitis consists of
the use of simple electrocauterv. Since the cer-
vix is devoid of sensory fibers, or nearly so, the
treatment is carried out in the office without the
use of general or topical anesthesia. Should
local anesthesia be found necessarv. either 10
per cent solution of cocaine hydrochloride or
Americaine solution may be found adequate.
We prefer to cauterize the external cervix before
the endocervical canal, since, generally, there is
more cramping with the latter procedure. We
use a radial cautery technic until all of the exter-

96

THE JOURNAL-LANCET

nal portion of the cervix up to and including the
entire site of erosion has been covered. Then the
endocervical canal is thoroughly cauterized. Be-
sides a Sims speculum, we use a Piper vaginal
retractor to keep the vaginal walls well away
from the field of operation.

It is important to tell the patient what to ex-
pect after the cautery has been done. The in-
sertion of Westhiazole vaginal suppositories or
a cream of triple sulfonamides lessens the odor-
ous discharge that may occur. The patient is in-
structed not to douche for ten days to two weeks
after cauterization and is advised to abstain from
sexual activities for approximately the same pe-
riod. She is usually told that after ten days to
two weeks, she will note a bloody, dark vaginal
discharge irrespective of her menstrual period.
However, should the menstrual period occur in
the ten-day to two-week interval, the flow is
often unusually heavy, and rest in bed is advised
during this time. All patients are encouraged to
report for re-examination two to three weeks
after the initial cautery and again after three to
six months. Patients who have undergone deep
cautery should be observed carefully for cervical
stenosis, and, before dismissal, the cervical canal
should be probed. Occasionally, after deep cer-
vical . cautery, it is necessary to use graduated
Hegar dilators to insure proper patency of the
cervical os or cervical canal.

FUNCTIONAL BLEEDING

Functional bleeding, as the name implies, means
hemorrhage from the uterus in which there are
no neoplastic or inflammatorv lesions. It is im-
portant to learn early whether the disturbance is
functional and, hence, whether the uterine bleed-
ing is originating from a proliferative or a secre-
tory tvpe of endometrium. The necessary tissue
may be obtained satisfactorily in the office in
practically all cases without anesthesia. The
Randall cannula curet is used for this purpose.
The caliber of the instrument is 4 mm., and it
can be introduced consistently into the uterine
cavity without previous dilatation. The cutting
edge of the cannula protrudes but little beyond
the periphery of the tube and allows removal of
the curet from the uterus with ease.

The actual technic used to remove tissue is
simple. The cervix and cervical canal are usually
prepared with an antiseptic, and the tip of the
cannula curet is carried to the fundus of the uter-
us. Firm pressure is placed against the uterine
wall, and then steady downward traction is
applied to the external os. Without removing the
instrument, the tip should again be carried to
the fundus and the procedure repeated in an-

other area. On withdrawal of the curet, the
specimens are found in the lumen of the instru-
ment, and they can be immediately expelled into
a fixing solution or, somtimes more conveniently,
onto thick blotting paper which is then immersed
into the solution. The blotting paper saves time
for the pathologist later on. This procedure
allows study of a considerable area of endome-
trium. Correlation of information obtained from
microscopic study of tissue removed, on the one
hand, and from the clinical history, physical ex-
amination, and estimation of the basal metabolic
rate, urinary estrin, and pituitary gonadotrophin,
on the other hand, have increased the accuracy
of diagnosis in cases of functional bleeding. Use
of the Randall curet is not advocated in patients
in whom a carcinoma of the endometrium is sus-
pected. It is better in such patients to resort to
cervical dilatation and uterine curettage.

DYSMENORRHEA

Dvsmenorrhea does not seem to plague the gyne-
cologist as much as it did years ago. However,
the various forms of treatment still are multiple
and many times complex. The pain in both pri-
mary and secondary forms of the condition is
most variable and may range from mere discom-
fort to severe agonizing pain in which the patient
may require hypodermic injections of narcotics.
Secondary or acquired dysmenorrhea is the tvpe
that usually responds well to treatment.

Examination of the patient should begin with
a complete physical appraisal and routine lab-
oratory tests, including determination of the
basal metabolic rate and the sedimentation rate.
The psychogenic background should be analyzed
carefully. Among the common causes of secon-
dary dysmenorrhea is pelvic inflammatory dis-
ease. Today, this may be present as a result of
infections from organisms other than the gono-
coccus. Heat therapy and short-wave diathermy
plus antibiotic therapy alleviate the dysmenor-
rhea that is on an inflammatory basis. Endome-
triosis is often suspected from the history.

Treatment in young girls should be conserva-
tive with the thought of preserving the child-
bearing function. Many of these patients re-
spond to the use of testosterone, estrogen, or a
combination of both. In more advanced cases of
endometriosis in which conservatism would be
ineffectual, surgical therapy must be used. Under
such conditions, the child-bearing organs should
be preserved in so far as possible. In older pa-
tients in whom the child-bearing function may be
sacrificed if necessary, the pelvis, including both
ovaries, should be cleaned out. In the younger
patients who are treated surgically, my col-

MARCH 1958

97

leagues and I prefer to do presacral neurectomy.

Primary dysmenorrhea is still the enigma of
the gynecologist, but most of the cases fit into
psychogenic, constitutional, local, or endocrine
categories. The treatment, of course, depends
upon the cause, which may be found from the
history to be a purely psychoneurotic one. A
low basal metabolic rate or general debility
should be corrected. When no specific cause is
found, various analgesics, such as aspirin, Phena-
cetin, combinations of aspirin, Phenacetin and
caffeine, or codeine should be tried. In cases of
primary dysmenorrhea that do not have a specific
cause, exercises have occasionally given much
relief by diverting the patient’s mind and in-
creasing circulation.

Endocrine therapy is not specific and does not
result in permanent cure. In many cases, how-
ever, estrogens or androgens are administered
for two to three months at a time to suppress
ovulation and relieve pain.

It should be mentioned parenthetically that
menstrual distress usually represents a combina-
tion of complaints, including periodic tension,
recurrent edema, uterine colic, and mastodynia.
Psychotherapy aimed at improving the patient’s
insight into the influence of emotions on physical
symptoms should be given over a long period of
time. To help relieve the hidden tissue edema, -
acetazolamide (Diamox) or aminometradine
(Mictine) may be prescribed for the week pre-
ceding the menstrual period. It is also suggested
that the patient take a low-sodium diet. This
regimen often relieves cyclic mammary pain as
well as headaches. The patient should also be
instructed to limit her fluid intake the week pre-
ceding her menstrual period. Ammonium chlor-
ide therapy has done much to call attention to
the theory of hidden edema, and, when used, it
should be started at least fourteen days before
the anticipated menstrual period.

The philosophy underlying the treatment of
dysmenorrhea is first of all that one should do
no harm. It is irrational to initiate a form of
therapy, the repercussions of which may be
worse than the dysfunction. Analgesics of the
opium series and some of the newer synthetic

drugs, such as alphaprodine (Nisentil) or me-
peridine (Demerol), are habit forming and
should not be used routinely or repeatedly. The
emotional component of dysmenorrhea has long
been recognized, and, certainly, suggestion enters
into any cure. Regardless of the cause of essen-
tial dysmenorrhea, some measures seem to pro-
vide partial relief, such as cervical dilatation and
uterine curettage, use of a stem pessary for var-
ious periods, pregnancy, and presacral neurec-
tomy.

SEXUAL FRIGIDITY

Complaints of sexual frigidity or sexual incom-
patibility are heard often. Clinically, of course,
such conditions have many facets and lead to
strange symptoms and signs which may conceal
the real problem. It is not surprising that these
complaints are frequent, since ignorance and
false information have long been the bugaboo in
the sexual life of the female. Many mothers still
tell their daughters that sexual relations are de-
grading, improper, or dangerous. Such teaching,
of course, leaves a permanent stigma on the mind
of the young girl, which greatly influences her
sexual behavior in adulthood. It is not unex-
pected, then, that some women develop and re-
tain a feeling of repulsion or disgust toward sex-
ual activity. Of course, not all frigidity is due to
psychogenic reasons. The majority of women
possess the capacity for pleasurable sexual activ-
ity. It is important that a wife should be com-
pletely satisfied sexually, for only then does she
become relaxed and productive in other activ-
ities. In order to advise her properly, the
physician himself must be aware of, and believe
in, the importance of good sexual adjustment and
its place in the attainment of good emotional
health. He should not have any prejudices con-
cerning sexual behavior, for, unless he is tolerant
and understanding, he will be unable to use
the psychosomatic approach. Many times, sym-
pathetic understanding of the patient in the
course of several visits is of great value in elimi-
nating unhealthy manifestations. Patients with
deep-seated neuroses and psychotic tendencies
should be referred to a psychiatrist.

98

THE JOURNAL-LANCET

Intermittent ( )bstructive Jaundice in
Hodgkin’s Disease:

o

Report of a Case

GRANT R. DIESSNER, M.D, and FRANK J. HECK, M.D.
Rochester, Minnesota

Jaundice is not uncommon in patients who
have Hodgkin’s disease. It has been reported
to occur in 3 to 6 per cent of cases,1- and some
observers think it occurs even more frequently,
since mild jaundice is overlooked at times or not
reported. However, jaundice developed in the
greatest number of the reported cases during the
terminal phase of the illness. The incidence of
intermittent jaundice in Hodgkin’s disease is un-
known, but it is thought to occur infrequently.

We are reporting the case of a patient who had
Hodgkin’s disease with intermittent jaundice in
whom the condition responded to treatment with
nitrogen mustard during 4 episodes of jaundice
in a period of two and one-half years. It is well
recognized that nitrogen mustard has a place in
the treatment of Hodgkin’s disease, but its use
in the presence of jaundice has been limited.
Dameshek and associates'1 expressed the opinion
that the presence of jaundice in Hodgkin’s dis-
ease is a contraindication to the use of nitrogen
mustard.

CASE REPORT

A 57-year-old white man, a pharmacist, was first seen
at the Mayo Clinic in January 1950. He complained of
progressive weakness, easy fatigability, backache, and
loss of 25 lb. during the past year. For nine months he
had noted abdominal fullness, bloating, and periumbilical
distress after eating solid foods.

Examination disclosed that the liver was palpable 2
fingerbreadths below the right costal margin. The tip of
the spleen was palpable. Multiple small, firm lymph
nodes were felt in the left axilla and right groin.

Urinalysis showed albumin graded 1 to 2 (on the basis
of 1 to 4), with positive results of tests for Bence [ones
protein; grade 1 erythrocytes and grade 3 pus cells were
present. The value for hemoglobin was 10.2 gin. per
100 ce. of blood. Erythrocytes numbered 4,070,000 per
cubic millimeter of blood. The leukocyte count was
24,800, with a differential count of 6 per cent lympho-

grant r. diessner is affiliated with the Section of
Medicine at the Mayo Clinic, frank j. heck is also
with the Section of Medicine at the Mayo Clinic and
is Professor of Medicine in the Mayo Foundation.

eytes, 4.5 per cent monocytes, and 89.5 per cent neutro-
phils. The erythrocytic sedimentation rate was 96 mm.
during the first hour (Westergren method). Roentgeno-
grams of the thorax, lumbar portion of the spinal column,
and the gallbladder showed nothing abnormal. The
values for urea clearance and for blood urea, calcium,
phosphate, amylase, lipase, and alkaline phosphatase
were normal.

Biopsy of lymph nodes disclosed Hodgkin’s type of
lymphoblastoma. Bacteriologic studies on the nodes
showed no growth. Roentgen treatment was given over
the abdomen, thorax, and back, but this therapy was in-
terrupted after 14 treatments because of leukopenia.

The patient returned five weeks later to complete his
course of roentgen therapy. He was feeling much im-
proved and had gained 13 lb. The leukocyte count was
normal, and the course of radiation therapy was com-
pleted without incident. The patient was dismissed in
April 1950.

He returned to the clinic for checkups in July 1950
and April 1951. He had no complaints at these times,
and significant abnormalities were not found. Treatment
was not given on either occasion.

In September 1951, the patient returned because of
fluctuating painless jaundice without fever. Occasional
dark urine and clay-colored stools had occurred during
the previous five weeks. Definite jaundice had been pres-
ent for nine days. Pruritus had appeared about three
days before admission.

The liver was firm, smooth, and palpable 2 finger-
breadths below the right costal margin. Results of rou-
tine hematologic studies were normal. Urinalysis showed
grade 2 albumin and grade 1 bile. The value for direct-
reacting serum bilirubin was 8.2 mg. per 100 cc\, and the
indirect-reacting type measured 1.8 mg. Thoracic roent-
genograms showed nothing abnormal.

The patient was admitted to the hospital for a trial of
nitrogen mustard with the provisional diagnosis of ob-
structive jaundice related to Hodgkin’s disease. A total
of 27 mg. of nitrogen mustard was given intravenously
in 2 doses; four days later, the direct serum bilirubin had
decreased to 2.74 mg. and the indirect was 1.7 mg. Two
days later, the values were 2.5 and 0.5 mg., respectively.
The patient felt greatly improved and returned home.

The patient returned in May 1952 because fluctuating
jaundice had recurred six weeks previously. He had been
free of jaundice since the aforementioned treatment with
nitrogen mustard. He felt well in the interval and had
continued to work. At the onset of this episode of jaun-
dice, he treated himself with bile salts, choline, and saline
cathartics, with some improvement. However, when this

MARCH 1958

99

self-medication was discontinued, the jaundice increased,
so he resumed medication and the jaundice became less
severe.

Results of examination were not remarkable except for
the mild jaundice. Serum bilirubin measured 1.37 mg.
direct and 0.75 mg. indirect. Bile was not found in the
urine. Values for serum protein, the albumin-globulin
ratio, hemoglobin, erythrocytes, leukocytes, platelets, pro-
thrombin time, and alkaline phosphatase were normal.
The differential count showed 11.5 per cent lymphocytes,
14 per cent monocytes, 72 per cent neutrophils, and 2.5
per cent eosinophils. Results of a thymol turbidity test
and roentgenologic studies of the thorax were normal.
Cholecystography was attempted but no function was
demonstrated.

The patient was given 27.5 mg. of nitrogen mustard
intravenously. The serum bilirubin showed no appre-
ciable change five days later, and surgical exploration of
the abdomen was advised. However, the patient decided
to return home and to postpone surgical treatment, as he
felt improved.

The patient returned in November 1953. Tire jaun-
dice again had cleared completely after the use of nitro-
gen mustard in May 1952, but it had recurred in Feb-
ruary 1953. A surgeon in his community had explored
the abdomen at that time and found a stricture of the
common bile duct and scarring in the duodenum. Chole-
cystostomy was done. Several small stones were removed
from the gallbladder, but none were found in the com-
mon bile duct. T-tube drainage was instituted, and the
jaundice cleared rapidly. The surgeon found no signifi-
cant intra-abdominal nodes or masses. External biliary
drainage was continued until June 1953. The patient
had lost 30 lb. in weight since the operation and had
noted progressive weakness. Jaundice had recurred three
weeks prior to this visit to the clinic, and he had experi-
enced retention vomiting during this period.

The liver was palpable 4 fingerbreadths below the
right costal margin, and the spleen was palpable. The
patient looked chronically ill and was extremely weak.
The value for hemoglobin was 11.3 gm.; ervthrocvtes
numbered 3,250,000; and the leukocyte count was 4,900.
The sedimentation rate was 92 mm. The serum bilirubin
measured 8.2 mg. direct and 1.0 mg. indirect. The value
for alkaline phosphatase was 86.2 King-Armstrong units.
Residts of other blood-chemical studies and of various
roentgenologic studies were normal.

Use of nitrogen mustard again was advised, and a
total of 24 mg. was given intravenously. Subjectively,
the patient felt greatly improved in twenty-four hours.
Three days after treatment, the serum bilirubin had de-
creased to 2.69 mg. direct and 0.81 mg. indirect. The
patient returned home and reported that the jaundice
cleared completely, only to recur late in January 1954.
Nitrogen mustard was given elsewhere, and the jaun-
dice again cleared and did not recur.

The patient returned for the last time in October 1954.
During the previous three or four months, he had ex-
perienced increasing anorexia, fullness in the abdomen,
vague abdominal distress, increasing weakness, nausea,
and occasional vomiting. He was ambulatory but was
pale, weak, and ill. A large, firm mass was palpable in
the epigastrium and right upper quadrant of the abdo-
men. The edge of the spleen was palpable on deep in-
spiration. Ascites and edema of both lower extremities
were present.

The value for hemoglobin was 10.8 gm. Erythrocytes
numbered 3,320,000, and the leukocyte count was 9,100.
The differential count showed 2 per cent lymphocytes,

12 per cent monocytes, 85.5 per cent neutrophils, and

0. 5 per cent eosinophils. Study of blood smears showed
increased rouleaux. The sedimentation rate was 65 mm.
Total serum proteins measured 3.48 gm. per 100 cc., with
1.98 gm. of albumin and 1.5 gm. of globulin. A test of
hepatic function using sulfobromophthalein showed grade
1 ( 10 per cent) retention of dye in one hour. The values
for blood urea and serum bilirubin were normal. Thoracic
roentgenograms showed fluid in both costophrenic angles.
Roentgenologic studies of the esophagus, stomach, and
duodenum showed an epigastric mass displacing the
lesser curvature of the stomach, but intrinsic involve-
ment of the stomach, duodenum, or esophagus was not
noted.

The patient received 2 blood transfusions of 500 cc.
each. Roentgen therapy over the entire abdomen was
given for six days. He improved, and, at the time of
dismissal, was eating well. One week later, he vomited
bright-red blood and passed tarry stools. He was hospi-
talized at home and the hematemesis continued. He was
given supportive blood transfusions, and, on November

1, 1954, abdominal exploration was done by his home
surgeon, who found a bleeding gastric ulcer and did a
partial gastric resection. Histologic study of the gastric-
wall disclosed Hodgkin’s disease. Hepatic biopsy done
at the same time showed diffuse fibrosis.

The patient’s condition became continually worse, with
progressive anorexia and loss of weight. He died in
February 1955. Necropsy was not done.

COMMENT

It is difficult to be sure of the pathophysiologic-
changes that produce jaundice in patients who
have Hodgkin’s disease. Multiple factors must be
considered. It is important, of course, to rule out
the usual causes of jaundice that are not related
directly to Hodgkin’s disease. Homologous serum
hepatitis resulting from previous parenteral in-
jections or transfusions and symptomatic hemo-
lytic anemia,4 such as that occurring in other
malignant diseases, may be responsible for jaun-
dice in these patients.

Hepatic involvement occurs in about half of
the patients who have Hodgkin’s disease,5 but
extensive changes in the liver are not common.
Beatty0 found widespread hepatic necrosis in
patients with Hodgkin’s sarcoma only when jaun-
dice had been present; necrosis of the liver was
absent in Hodgkin’s disease not associated with
jaundice. However, the group of patients studied
was small, and the hepatic necrosis may have
been related to treatment rather than to the pres-
ence of Hodgkin’s disease.

Obstructive jaundice caused by Hodgkin’s dis-
ease may occur. This diagnosis is made by ex-
cluding the commoner causes of obstructive jaun-
dice, as was done in the case just reported.
Hodgkin’s disease can produce obstructive jaun-
dice primarily bv 3 methods : namely, ( 1 ) com-
pression of the main biliary ducts by adjacent
tumor or involved nodes, (2) obliteration of the
main extrahepatic ducts as the result of ductal

100

THE JOURNAL-LANCET

involvement by Hodgkin’s granuloma, and (3)
involvement of the intrahepatic duets. Compres-
sion of the common bile duct by enlarged peri-
biliary nodes involved by the granulomatous
process is probably the most common explana-
tion given and is the assumed mechanism of
jaundice in many reports in the literature. Ex-
amination at necropsy or surgical exploration
frequently fails to bear out this explanation. The
case report by Pepper7 is illustrative of this point.
The clinical diagnosis was obstruction of the
common bile duct by nodes involved by Hodg-
kin’s disease. However, the surgeon was unable
to find any nodes that obstructed extrahepatic
biliary drainage, and the cause of the jaundice
was not ascertained.

Beatty'* recently reported the necropsy findings
in 23 cases of Hodgkin’s disease in which jaun-
dice was present at the time of death. In only
2 of these was the jaundice thought to be caused
by extrahepatic obstruction, namely, by para-
choledochal lymph nodes in 1 case and by ob-
struction at the porta hepatis in the other. How-
ever, microscopic evidence of extrahepatic ob-
struction was not present in any of these cases.
Beatty found diffuse involvement of the portal
trinities by fibrotic Hodgkin’s disease in the
patients who were jaundiced, whereas the pat-
ients who had hepatic involvement but who were
not jaundiced failed to show such involvement
of the portal trinities. Jackson and Parker8 re-
ported that jaundice caused by compression of
the bile ducts by surrounding granulomatous
tissue is rare. Barron’s9 study of necropsy mater-
ial showed that peribiliary infiltration produced
jaundice more frequently than did pressure by
enlarged nodes or masses against the large ducts.
Thus, obstructive jaundice in Hodgkin’s disease
is caused most frequently by intrahepatic in-
volvement, less often by direct involvement of
biliary ducts, and only rarely by compression of
extrahepatic ducts by tumor or involved nodes.

Surgical exploration of our patient, while be
was jaundiced in February 1953, failed to reveal
any nodes or masses compressing the large bile
ducts. A stricture of the common duct was re-
ported, which suggests that the common duct
was involved directly by tumor. External biliary
drainage at that time promptly relieved the jaun-
dice, so intrahepatic involvement probably was
not a factor in the jaundice. Unfortunately, the
extent of hepatic involvement never was deter-
mined in this patient.

The effect of nitrogen mustard on tissue af-
fected by Hodgkin’s disease is not well known
because of lack of suitable material for studv at
proper intervals before and after treatment. The

histologic studies of Spitz10 showed that promi-
nent changes occurred within seven days after
treatment in the 2 cases of Hodgkin’s disease
she studied before and at suitable intervals after
treatment with nitrogen mustard. She noted no
specific changes in the hepatic cells as the re-
sult of use of nitrogen mustard.

In studies on rabbits into which mustard gas
containing radioactive sulfur was injected, Bours-
nell and associates11 noted that the kidneys,
liver, and lungs were the main excretory organs
for nitrogen mustard. Large quantities of this
material were found in the bile and urine during
the first hour of collection after injection. If
great amounts of nitrogen mustard are excreted
in the bile by way of the liver in human beings,
damage to hepatic cells may well occur.

Necrosis of hepatic cells has been reported in
patients with Hodgkin’s disease who received
nitrogen mustard.3,6 However, not all of the
cases in which hepatic necrosis has been found
at necropsy are reported in detail, so it is im-
possible to know whether nitrogen mustard was
given in all cases and if, when given, it was
responsible for the necrosis.

Dameshek and associates3 reported 4 cases
of patients who had Hodgkin’s disease with
hepatomegaly and jaundice to whom nitrogen
mustard was administered. Response to treat-
ment was good in 2, but the condition in the
other 2 became worse. Only 1 of these cases is
reported in detail; the patient concerned did not
have obstructive jaundice and was critically ill
when treatment was undertaken. In their group
of 50 patients to whom nitrogen mustard was
given, Dameshek and associates reported hepatic
necrosis at necropsy in 3. It was considered
likely that the necrosis could be attributed to the
nitrogen mustard.

It is apparent that the causes of jaundice in
Hodgkin’s disease are so many and so varied
that the jaundice alone cannot be the determi-
ning factor in the use or contraindication to the
use of nitrogen mustard. A trial of treatment
with nitrogen mustard appears worthwhile for
those patients who have Hodgkin’s disease
associated with jaundice, particularly if the jaun-
dice is of the obstructive tvpe.

SUMMARY

A report has been given of a case of a patient
with Hodgkin’s disease in whom intermittent
obstructive jaundice developed. The jaundice
was relieved on 4 occasions by use of nitrogen
mustard. The successful administration of nitro-
gen mustard in this case lends support to the
opinion that the presence of jaundice does not

MARCH 1958

101

contraindicate use of nitrogen mustard in Hodg-
kin’s disease.

The current concepts of the mechanisms res-
sponsible for the production of jaundice in Hodg-
kin’s disease are reviewed. It is emphasized that

REFERENCES

1. Minot, G. R., and Isaacs, R.: Lymphoblastoma: aspects con-
cerning abdominal lesions, especially their production of early
symptoms. Am. J. M. Sc. 172:157, 1926.

2. Goldman, L. B.: Hodgkin’s disease: an analysis of 212

cases. J.A.M.A 114:1611, 1940.

3. Dameshek, W., Weisfuse, L., and Stein, T.: Nitrogen mus-
tard therapy in Hodgkin’s disease; analysis of 50 consecutive
cases. Blood 4:338, 1949.

4. Stats, D., Rosenthal, N., and Wasserman, L. R.: Hemo-
lytic anemia associated with malignant diseases. Am. J. Clin.
Path. 17:585, 1947.

5. Lichtman, S. S.: Diseases of Liver, Gallbladder, and Bile

Ducts, 3rd ed. Philadelphia: Lea & Febiger, 1953, vol. 2,
pp. 1079-1080.

6. Beatty, E. C., Jr.: Jaundice in Hodgkin’s disease. Bull. New
York Acad. Med. 30:409, 1954.

intrahcpatic involvement or direct involvement
of the main bile duct in Hodgkin’s disease is
more likely to cause obstructive jaundice than
is pressure or compression of the extrahepatic
bile ducts by enlarged peribiliary nodes or tumor.

7. Pepper, O. H. P.: Hodgkin’s disease with jaundice as an

early symptom; illustrative case. M. Clin. North America
March:’ 1449, 1920.

8. Jackson, H., Jr., and Parker, F., Jr.: Hodgkin’s Disease and
Allied Disorders. New York: Oxford University Press, 1947,
177 pp.

9. Barron, M.: Unique features of Hodgkin’s disease (lympho-
granulomatosis ) : with report of 3 unusual cases and a sum-

mary of 24 cases studied at necropsy. Arch. Path. 2:659,
1926.

10. Spitz, S.: Histological effects of nitrogen mustards on human

tumors and tissues. Cancer 1:383, 1948.

11. Boursnell, J. C., and others: Studies on mustard gas ( pp
dichlorodiethyl sulphide) and some related compounds; fate
of injected mustard gas (containing radioactive sulphur) in
the animal body. Biochem. J. 40:756, 1946.

f

The incidence of gangrene in diabetic persons is related to infection but not
to insulin requirement or known duration of diabetes.

Gangrene is sometimes the presenting symptom with diabetes. Probablv,
a long period of undiagnosed, slight diabetes precedes this manifestation.

Gangrene is often fatal. In some patients, some other manifestation of
generalized atherosclerosis is the immediate cause of death and gangrene is
contributory. Occasionally, patients die of an unrelated disease.

Survival after amputation is longer with diabetic than with nondiabetic
gangrene, since vascular obstruction is less severe in the former group.

Advanced hyalinization of the juxtaglomerular segment of the afferent renal
arterioles probably indicates diabetes or a prediabetic state. This condition is
13 times as frequent in diabetic as in nondiabetic patients. Intracapillary glom-
erulosclerosis, not observed in nondiabetic persons, appears in 48 per cent of
diabetic patients.

Atherosclerotic gangrene is 53 times as frequent in diabetic as in nondia-
betic men over 40 years of age and 71 times as frequent in diabetic as in non-
diabetic women of the same age. In men under 80 years of age, two-thirds of
all instances of atherosclerotic gangrene are associated with diabetes. In wom-
en, approximately 80 per cent of atherosclerotic gangrene results from diabetes.

E. T. Bell, M.D., University of Minnesota, Minneapolis. Am. J. Clin. Path. 28:27-36, 1957.

102

THE JOURNAL-LANCET

Immediate Planning for Definitive Treatment
of Severely Injured Individuals
with Multiple Fractures

GEORGE L. DIXON, M.D.

Tucson, Arizona

It ocgured to us approximately a year ago,
when caring for a patient with multiple in-
juries incurred as a result of a violent accident,
that we were using the same general plan of
treatment that we had used for well over three
decades. This plan consisted of four parts:

1. First aid.

2. General examination and planning for definitive
treatment.

3. The use of consultants.

4. The general management, supervision, total han-
dling of the case by one man.

It further occurred to us that a plan to have
been followed for so many years must have had
some merit, for, judging by the survival rate of
such victims and the percentage of those restored
to full function, the modern medicine of the
middle “20's,” when compared to present knowl-
edge, was as immature as medicine of the middle
“90s” was to medicine of the middle “20’s.”

Bear in mind while reading this paper that
the author is an orthopedist and that the title
is not entirely accurate in stressing multiple
fractures, as there has been gross insult to many
of the soft tissues in accidents of violence. The
survival of the victim and his restoration to
function may depend on the recognition and
treatment of these injuries, as well as treatment
of the fractures. The victim of today has the
additional advantages of:

1. Rapid communication.

2. Rapid transportation.

3. Organized and well equipped emergency rooms in
hospitals with complete equipment.

4. Increased medical knowledge, including specializa-
tion.

5. Modern and present day teamwork within the med-
ical profession.

George l. dixon is a specialist in orthopedic surgenj
with offices in Tucson, Arizona.

Paper presented at the annual meeting of the
American Fracture Association in El Paso, Texas,
October 1, 1957.

Before presenting the plan used today, let us
visualize the victim with multiple serious in-
juries caused by an automobile accident, the
most common accident of violence in this era.
The police officer arrives shortly after the acci-
dent and directs the first aid in addition to his
other duties, using his short-wave radio to call
an ambulance and, on its arrival, he figuratively
heaves a sigh of relief and turns the patient over
to the care of attendants for possible additional
first-aid treatment. The purpose, as in all first
aid, is “to prevent further injury.” The victim is
transported rapidly to an emergency room of the
nearest hospital, where a “glorified” type of first
aid can be practiced because of the organization
and equipment. We use the term “glorified
because all supplies and hospital services are
available. As soon as possible, ambulance at-
tendants and emergency room personnel place
the victim on a wheeled cart on which he may be
treated for many hours or transported to other
parts of the hospital without gross handling. At
this time, the patient is given a complete, rapid,
general examination for total evaluation, and a
working diagnosis can be adequately accomp-
lished and additional special services available
in the hospital can be called upon. In making
this evaluation, we have found it useful to ex-
amine the various bodily systems, consisting of
the nervous, cardiovascular, upper respiratory,
musculoskeletal, and the genitourinary systems,
in order to determine which has been subject to
the greatest trauma and the effect upon the other
systems.

The plan used today has the same principal
parts as it did originally.

1. Under the auspices of the county medical
society, a parent organization of all medicine in
the community, with the aid of the Red Cross,
regular first-aid instruction is given preferably
by a doctor as an instructor to: (a) all police
officers and (b) owners, operators, and attend-
ants of ambulances.

MARCH 1958

103

The latter, by virtue of their occupation, care
for more victims than does a single police officer.

2. Emergency room. Again, under auspices of
the county medical society, the staffs of the var-
ious hospitals are made responsible for the organ-
ization and equipment of their emergency rooms
and hospitals.

a. Glorified first aid.

b. General examination, evaluation, and plan-
ning for definitive treatment of the victim.

Here, it should again be pointed out that with
the victim on a wheeled cart, not only the ex-
amination but many forms of treatment can be
accomplished. Also, when the patient is to be
moved to another part of the hospital, he will
not require further gross handling, and, if he is
to go to his room, arrangements can be made for
certain equipment to be present on his arrival.
If he is to be transferred to an operating room,
personnel and equipment can be made ready,
converting the emergency operating room pro-
cedure to a planned procedure.

3. Consultants. The part played by consultants
in medicine of today does not require explana-
tion, which leads us to a discussion of con-
sultants employed by the physician or surgeon
in charge and their possible abuse of the victim.
In most instances, after the physician or surgeon
in charge chooses a consultant, he must then
decide how soon he should see the patient. Ordi-
narily, a physician’s general knowledge enables
him to administer the preventive and early treat-
ment, but, in some instances, it is best to tele-
phone the consultant, giving him a general pic-
ture of the case, asking him for suggestions for
immediate treatment, and arranging for him to
see the patient. Certainly, in all requests for con-
sultants on accident cases, the man in charge
should be the one to present to them the over-
all picture. The patient may suffer abuse at any
time after the consultants’ arrival, since nothing

contuses any emergency room crew to the detri-
ment of the victim’s welfare more than an ex-
amination and orders given by one or more con-
sultants at the same time. Furthermore, even
after the critical period and later, multiplicity of
orders continues to confuse the personnel and is
detrimental to the patient’s welfare.

4. General management and supervision by
one physician or surgeon. At this point, we have
admitted a very definite need for consultants,
but all of us who limit our practice to one field
of medicine are apt to have a common failing of
“tubal-vision,” and, as a result, easily forget
momentarily the patient as a whole. For that
reason, one physician should supervise the orders
so that they can be timed properly and allow the
victim the physiologic rest necessary for his re-
covery without neglecting any particular injury.
This is more easily arranged if the same team
always works together, but any team can ac-
complish the same objective by using the tele-
phone and considering suggestions made by the
several consultants.

The past medical history and general condi-
tion of the patient just prior to the accident are
quite as important in an accident case as in any
other seriously ill individual, and this information
c^n be gradually acquired from friends, relatives,
and the patient. The cause of the accident and
its degree of violence must also be considered
and can be gained in part from the police officers,
ambulance attendants, others in the accident,
and witnesses, as well as, possibly, the patient.

Presentation of this paper was concluded by
the use of a double screen, and, for each case on
one side of the screen not discussed, the compli-
cations, and list of consultants, the slide gave a
brief history, the multiple diagnoses, the past
medical history, while, on the other side, multiple
plates were used to illustrate interesting ortho-
pedic problems brought out by these cases.

104

THE JOURNAL-LANCET

The Medicinal Treatment of Asthma

J. HARVEY BLACK, M.D.
Dallas, Texas

All physicians regardless of the field of medi-
cine in which they practice, have occasion,
at one time or another, to meet the pressing prob-
lem of offering relief to someone suffering from
severe asthma and for whom help is urgently
needed. I should like to offer some suggestions
which may be of help under those circumstances.

There are many medicinal agents available.
Some are much more effective than others; some
act more rapidly than others; some have fewer
contraindications than others; and some should
not be used at all. Let us run rapidly over the
list.

For the sake of emphasis let me say first that
opiates should not be used in anv form. In my
own experience, I have seen as many deaths
occur from the use of an opiate in the treatment
of the asthmatic paroxysm as I have from the
asthmatic attack itself. There is some argument
as to the mechanism that causes death but none
concerning the fact that it occurs. Many patients
can tolerate an opiate well, but its continued use
in asthmatic patients sooner or later results in
death. This interdiction applies to all opium
derivatives. If an opiate is given, an ampule of
Nalline should be on hand, and the patient
should not be left alone unless someone is avail-
able to administer it in case of necessity. On two
occasions, in the hands of my associate, Nalline
has been lifesaving.

The steroids have been much in the public
eye and have come into general, even indiscrimi-
nate, use. They are used much more often, 1
think, than is desirable. They usually relieve
attacks of asthma which fail to respond to the
usual measures, and, consequently, they can be
of great help in such difficult situations. But, the
steroids or ACTH do not bring relief as rapidly
as epinephrine and should not be used unless and
until the latter has been tried and failed. To my
mind, long continued use of any steroid for the
treatment of asthma is not justified unless all
other measures have failed. I believe the steroids
are only helpful as emegency medications. There
are exceptions, of course, to this rule but they

j. harvey black, a specialist in allergies, maintains
offices in Dallas, Texas.

should be few. We have seen a few patients with
constant asthma that was resistant to all conven-
tional means of relief who could be kept alive
and in comparative comfort with daily doses of a
steroid. Under these circumstances, we feel that
the continued use of these agents is justified.

Epinephrine is still the most valuable drug for
the treatment of asthma. Its action is rapid and,
in most instances, effective. Its side effects are of
little importance. Continued use does not lead to
addiction nor does it damage the cardiovascular
system. It may be used both as a watery solution
and a suspension in oil. In oil, the action is more
prolonged but also slower in its onset so that a
choice should depend upon whether long pro-
tection or rapid relief is most needed. Often, un-
necessarily large doses are given, resulting in
pallor, tachycardia, and tremor. I am convinced
that 0.5 cc. is fully as effective as a larger dose.
Except in grave emergencies, intravenous epine-
phrine is not indicated. If the need should arise,
it may be instilled into the vein a drop at a time
or, better, diluted by saline or glucose solution.
One should be prepared for the fact that even a
single undiluted drop into a vein may precipi-
tate a violent, occipital headache.

Epinephrine in oil is supposed to be absorbed
over a much longer period than the watery solu-
tion, but it should be remembered that it is a sus-
pension in oil and, sometimes, is absorbed more
rapidly than is expected or desired. Since the
dosage employed is usually twice the amount of
the drug in solution, symptoms of overdosage
may occur, consisting of pallor, tachycardia, and
tremor.

The use of epinephrine by inhalation is help-
ful in the patient having recurrent, mild attacks.
It does not control severe attacks, as do hypoder-
mic injections, but for those less severe, it is
quite convenient and can be used promptly in
the beginning of an attack. This is important,
for, with epinephrine as with other forms of
medication, an asthmatic attack can best be con-
trolled by the earliest possible medication.

Norepinephrine (Arterenol) also is produced
by the adrenal medulla. It, too, is a vasoconstric-
tor with little or no effect on cardiac output and
little hyperglycemic action. Commercial epine-

MARCH 1958

105

phrine contains approximately 15 per cent nore-
pinephrine. It is effective in the relief of asthma.
Isopropylarterenol is available as Isuprel, which
may be nsed by inhalation and sublingually and
as Norisodrine, which is used as an inhalant
powder. In a considerable number of patients,
these agents produce so much cardiac stimula-
tion that patients refuse to continue their use.
In those who do not suffer these effects, they may
he effective but seldom provide as much relief as
< Iocs epinephrine when it is administered hypo-
dermically.

Ephedrine has been used for the past thirty
years. It has advantages over epinephrine in that
it may be used orally, as a preventive, and its
action is much more prolonged. Its disadvant-
ages are that it is less potent and that central
stimulation often so disturbs the patient that it
cannot be used. It may be used orally, sub-
cutaneously, or reetallv, alone or, more frequent-
ly, in combination with other drugs. Recephe-
drine, which is racemic ephedrine, is not as effec-
tive as 1-ephedrine, hut it does not produce as
much central stimulation and often can be used
when 1-ephedrine cannot. To retain the effec-
tiveness of ephedrine and avoid its side effects,
many synthetic substances have been made,
such as Neo-Synephrine, Propadrine, Nethamine
and others, all of which are less likely to disturb
the patient but also are less effective.

The xanthine compounds are quite helpful.
Even a cup of hot coffee may give much relief,
though whether this is due to the heat or caffe-
ine is questionable. Theophylline and aminophyl-
line are in quite general use. They may be
administered orally, reetallv, or intravenously.
When injected into the muscle, they cause such
severe pain that, in my opinion, they should
never be so used. Even a little leakage from an
intravenous injection is very painful and should
be carefully avoided. A rectal suppository some-
times is almost as effective as an intravenous in-
jection. The intravenous injection of as much as
0.5 gm. often relieves attacks that are resistant to
epinephrine. Some severe reactions and a few
deaths have been reported from the intravenous
use of aminophvlline, but I have not seen one.
Very slow injection, taking at least five minutes
for the introduction of 0.5 gm„ has not produced
any reactions in our experience. Enteric-coated
tablets taken at bedtime often protect patients
through the latter part of the night, which is the
time when an asthmatic attack usually occurs.
The uncoated tablet or the suppository taken at
bedtime does not remain effective until the early
morning hours, which is the time when protec-
tion is needed most.

Potassium iodide, an old and valuable remedy,
is not of service in the relief of the immediate
asthmatic attack but, over a period of days, may
produce a more liquid sputum and, by lessening
the severity of the cough, it prevents the develop-
ment of severe dyspnea.

Recently trypsin and Alevaire (a detergent
compound ) have been used by inhalation and
seem to be helpful in the presence of much tena-
cious mucus. Personally, I still wonder if they
are much more effective than the iodide. Inci-
dentally, since the iodide is absorbed so rapidly
when given by mouth that it is detected in the
saliva in thirty minutes, intravenous injections
are seldom needed. It should he kept in mind
that sooner or later an acneform eruption or
gastric distress may develop in some patients
from the iodide. Rarely, a parotid swelling or
edema of the nasal mucosa with rhinorrhea de-
velops.

Glucose and water are lost rapidly in a severe
asthmatic attack and should be replaced. Prob-
ably nothing helps a patient in status asthmaticus
more than a considerable amount of glucose and
water. If he is able to swallow and to retain
fluid, it may be given by mouth, and corn syrup
may be used. Sweetened fruit juices given fre-
quently can be used to advantage.

1 am convinced that oxygen is not needed in
the treatment of asthma as often as it is used.
If the patient is in status asthmaticus and is
cyanotic, oxygen may he helpful. It should be
remembered that in the acute attack, the patient’s
difficulty is not due to the lack of oxygen in the
respired air but to the narrowed tube through
which he tries to breathe. If the lumen of the
tube can be increased by medication, he usuallv
has no difficulty in acquiring as much oxygen as
he needs. In instances in which medication is
not producing the desired result and cyanosis has
ensued, oxygen may be helpful. Even in such
cases, it should be watched carefully if it is con-
tinued for some time, since it is not without
danger. These patients may show hypoxemia and
an increased pC02 and lowered pH. With the
loss of the drive for respiration due to the hv-
poxia and a possible loss of sensitivity of the
medullary centers for pCCV, respiratory failure
may occur. Continuous administration may cause
pulmonary irritation, stupor, coma, and con-
vulsions.

The antihistaminic drugs are seldom of much
help in an asthmatic attack. Why they should he
helpful in the treatment of hay fever and of
relatively little value in asthma, we do not know.
That this is not generally recognized is shown
by the fact that a large per cent of the asthmatic

106

THE JOURNAL-LANCET

patients referred to us have had no previous
medication other than astihistaminic drugs.

Another practice with which I do not agree
is the general use of antibiotics in asthmatic
patients with no evidence of infection. Patients
with asthma may also have a respiratory in-
fection for which an antibiotic may be indicated,
but asthma is not an infectious disease and is
not favorably influenced by antibiotics except
when an intercurrent infection is present.

Piromen is a suspension of a sterile bacterial
polysaccharide which, in enormous dilution, has
been recommended for the relief of asthma. We
have not found it of value.

For some obscure reason, aspirin occasionally

relieves asthma. Five grains are sometimes as
effective as 0.5 ce. of epinephrine. Since some
persons are dangerously sensitive to aspirin, it
should not be prescribed until its safety has been
established.

Alcohol has been effective in some patients
but many are made worse by it.

Arsenic has been used in the celebrated “Gay
formula and seems to be of some help if con-
tinued over considerable time. It is, of course,
a dangerous drug if used over long periods.

None of our medicinal agents cures asthma,
but, if used to best advantage, the physician can
relieve much suffering and earn the gratitude of
distressed and frightened patients.

In recent years, the incidence of paralytic poliomyelitis in adults has in-
creased. Because of this increase and because poliomyelitis tends to lie more
severe in older patients, immunization of adults is as essential as immunization
of children.

Pure spinal poliomyelitis is the most common form of paralytic poliomyelitis
in all age groups. Incidence of bulbospinal poliomyelitis increases with age,
being about 7 per cent in children under 5 years of age and about 40 per cent
in patients over 40 years old.

Extent of involvement with spinal paralysis also varies with age. In pa-
tients less than 5 years of age, monoplegia is most common; monoplegia and
paraplegia are most frequent in patients 6 to 15 years old, while quadriplegia
occurs in about one-half of patients over 15 years of age. In patients with
monoplegia, the left side is more often affected than the right.

Bladder paralysis is more common in adults than in children, affecting one-
third or more of patients 16 years of age or older. Respiratory muscle paralysis
is 9 times as frequent in adults as in children. Mortality from paralytic polio-
myelitis also increases with age. About 3.1 per cent of patients under 16 years
of age, 8.5 per cent of those 16 to 30 years old, and 29.6 per cent of those
40 vears of age or older die of the disease.

Sex also influences manifestations of poliomyelitis. More male than female
children have paralytic disease, but adult women are affected more often than
adult men. Disease tends to be more severe in female children and in adult
males. Quadriplegia, respiratory paralysis, and death are more common among
adult men than among women. Men over 40 years old appear to be most
susceptible to severe paralytic poliomyelitis.

Louis Weinstein, M.D., Boston University, New England J. Med. 257:47-52, 1957.

MARCH 1958

107

Health of the American Indians

HERBERT A. HUDGINS, M.D.
Aberdeen, South Dakota

On July 1, 1955, the Public Health Service,
Department of Health, Education, and Wel-
fare, took over administration of the medical
program for Indians and Alaska natives. This
responsibility was transferred from the Bureau
of Indian Affairs, Department of the Interior,
under the terms of Public Law 568, 83rd Con-
gress, 2nd Session. To conduct this program, the
Public Health Service organized the Division of
Indian Health as part of its Bureau of Medical
Services.

The provision of health services to the Indians
has long been recognized as a federal obligation.
Historically, this responsibility dates from the
time the Indians were located on reservations
by the federal government and were under the
jurisdiction of the War Department. In 1849, the
Department of the Interior was made responsible
for Indian affairs, and later a program for med-
ical care and health services was developed.
In later years, the technical leadership for the
health program within the Department of In-
terior was rendered by officers assigned from
the Public Health Service. The existence and
continuity of this knowledgeable leadership since
the transfer of responsibility on July 1, 1955, have
resulted in the maximum increase of services
compatible with available funds.

The program of the Division of Indian Health
is administered through 6 area offices in Port-
land, Oregon; Aberdeen, South Dakota; Okla-
homa City, Oklahoma; Albuquerque, New Mex-
ico; Phoenix, Arizona; and Anchorage, Alaska.
Services are provided for approximately 315,000
Indians living on about 250 reservations in 24
states and approximately 35,000 natives in the
Territory of Alaska. Excluded are sizable num-
bers of Indians living in the East whose care is
not a responsibility of the federal government.
Also excluded are those Indians who have volun-
tarily moved away from their reservations, most-
ly to the larger cities, and beyond the effective
reach of Division of Indian Health facilities.

Herbert a. hudgins is a medical director in the Unit-
ed States Public Health Service and area medical of-
ficer of the Division of Indian Health, United States
Public Health Service, Aberdeen, South Dakota.

The health status of the American Indian is,
in general, that of any underprivileged group.
The high disease indices always quoted pertain
to those remaining on reservations and not to the
thousands who have become a part of the dom-
inant culture. There appears to be no predilec-
tion for certain diseases, but rather we observe
the high rates in diseases identified with low
economic resources. Those of us in the Indian
health program feel that the socio-economic dis-
advantages prevalent among the Indians must
be solved concomitantly with any marked im-
provement in their health status. In spite of the
deficiency in such necessities as housing, cloth-
ing, food, transportation, and so forth, we find
real concern among the Indians in regard to
health matters and an increasing acceptance of
recognized health procedures.

» Recognition of the high incidence of prevent-
able diseases is given in the 1956 annual report
of the Department of Health, Education, and
Welfare, which reads, “Historically, our Indians
and Alaska natives have been isolated both geo-
graphically and culturally from the mainstream
of progress that brought health records to each
succeeding generation of Americans. The health
needs of these people are critical. Their average
age at time of death, for example, is 39 — com-
pared with 60 for the general population.

“Most of their illnesses are tragically due to
causes that can be prevented. For this reason,
the Public Health Service has accelerated its
program of disease prevention. More than $4.3
million was spent in this effort during the year,
and more than 500 of the 4,150 Indian health
staff were engaged in preventive health activi-
ties.”

The Public Health Service realizes that any
health program of lasting value must be devel-
oped with the people concerned. Accordingly,
at the reservation level, every effort is made to
encourage self-reliance and independence on the
part of the Indian people, and their participation
is sought in planning health activities. The speed
and success in this cooperative planning natural-
ly vary as they would in any population group.
The Indians are also assisted in making use of
state and local services of health, vocational re-

108

THE JOURNAL-LANCET

habilitation, and crippled children’s agencies.

At the national level, judgment of the Indians
and other authorities is obtained through an Ad-
visory Committee on Indian Health named by
the Surgeon General in May 1956. This com-
mittee, with members representing medicine,
science, law, education, journalism, and the In-
dian peoples, is aiding in the development of
policies to improve health services to the Indians.

The goal is to develop a total health program,
with equal importance given to the two major
phases — preventive and curative. This will he
obtained through direct operation by the Public
Health Service when necessary or bv contract
services where such are possible and feasible.
Full integration of both phases is also a goal as
each supplements the effectiveness of the other.

In compliance with a request of the House
Committee on Appropriations of the 84th Con-
gress, 1st session, a comprehensive survey of
Indian health needs was made. This report con-
tains the following description of some communi-
ties among Northern Plains Indians that must be
changed to gain the optimum in health progress.

ECONOMIC RESOURCES

“With the exception of one small reservation,
both land resources and employment opportuni-
ties were considered to be wholly inadequate to
support the population. On the largest reserva-
tion in the area, it was estimated that not more
than a third of the present population could be
supported from reservation resources even as-
suming more efficient use. Far less than this
number were being supported at the time of the
survey. On another reservation, approximately
5,000 Indians lived on land which could not
support more than a tenth of that number. On
a number of reservations, even the inadequate
amounts of land available were not being used
fully by Indians, and the trend seemed to be
toward decreasing use. The sale of land had
been increasing.”

WATER SUPPLY

“The community provides itself with water from
four wells and three sunken barrels placed in
excavations in an intermittent stream bed. The
only well that approaches sanitary approval is
that at the school. An outside faucet on the
pump house is maintained for the Indians to use
as they wish. Fifty per cent of the households
obtain their water here. Twenty per cent haul
their water by automobiles, 20 per cent by wag-
on, and 60 per cent by hand. Milk cans, buckets,
and barrels are used — none of which even ap-
proaches sanitary standards. Hauling distances

range from 50 to 700 yd., averaging about 400
yd. No disinfection of any kind is practiced.”

EXCRETA DISPOSAL AND FLIES

“In the entire community (excluding the school),
there is only one privy that meets sanitary stand-
ards. Every one of the others needs complete re-
habilitation. Five families have no privies of
their own. They share the facilities of neighbors.
The most bothersome insects reported are Hies,
mosquitoes, and fleas — mostly fleas. Screens are
absent from more than 60 per cent of the houses,
and the unprotected outdoor cooking, eating,
and sleeping in the summer provide these pests
with abundant fresh food and human prey.”

HOUSING

“Slightly over 75 per cent of the houses are of
mud-caulked logs and earth covered roofs. About
20 per cent are of frame construction, 1 of these
being of a log-frame combination. The remain-
ing 5 per cent are classified as shacks, being
thrown together with scraps of building material
of any kind. The largest number of persons per
dwelling is 11, the minimum 1, the average
about 3. Although the average may seem low,
the small size of the homes, in general, causes
overcrowding. Slightly over 40 per cent have
only 2 rooms, this being the maximum number
of rooms in any habitation.”

Such adverse environmental conditions over a
period of several generations can well account
for the facts that 33 per cent of the deaths
among Indians occur before the fifth year of life,
whereas only 8 per cent of the deaths in the gen-
eral population are in this age group; that the
Indian death rate from influenza and pneumonia
is nearly 4 times that of the general population;
that the death rate for tuberculosis is 5 times
greater, and for enteric diseases 10 times greater
than corresponding death rates in the population
as a whole.

There are approximately 36,900 Public Health
Service Indian beneficiaries in the 2 Dakotas and
Nebraska. A review of certain communicable
disease rates per 100,000 population reveals:

1952

1953

1954

1955

1956

Tuberculosis, all forms

609.4

584.2

593.9

663.9

634.2

Influenza

203.1

3,313.8

2,661.1

81.3

46.1

Pneumonia

817.7

1.283.2

2,095.2

1,512.2

2,192.4

Diphtheria

13.0

2.6

2.8

10.8

5.4

Whooping cough

67.7

15.3

207.3

192.4

723.6

Poliomyelitis

26.0

25.5

2.8

8.1

5.4

Measles

658.9

377.6

596.6

514.9

1,124.7

Gonorrhea

466.1

607.1

753.5

929.5

916.0

Syphilis and sequelae

299.5

247.4

252.1

409.2

238.5

Typhoid fever

5.2

10.2

8.4

19.0

2.7

Dysentery, all forms

875.0

637.8

92.4

393.0

94.9

MARCH 1958

109

In this same population group and for the
same years, the leading causes of death per
100,000 population were:

1952

1953

1954

1955

1 956

1. Heart diseases

181.8

145.4

137.3

86.7

149.1

2. Accidents, total

114.3

68.9

75.6

67.7

119.3

3. Tuberculosis, all forms

143.7

89.3

78.4

48.8

62.3

4. Symptoms,

senility, ill-defined

129.0

68.9

42.0

75.9

84.0

5. Malignant neoplasms

90.9

48.5

72.8

43.4

56.9

6. Vascular lesions affecting
central nervous system

55.7

30.6

36.4

46.1

35.2

7. Certain diseases peculiar
to early infancy and
immaturity unqualified

29.3

10.2

33.6

29.8

43.4

S. Gastritis, duodenitis,

enteritis, and colitis

26.4

23.0

22.4

35.2

27.1

9. Birth injuries, postnatal
asphyxia, atelectasis

29.3

30.6

14.0

32.5

13.6

10. Infections of newborn

20.5

17.9

22.4

21.7

16.3

The numerical standing of the preceding fig-
ures is based upon the five-year average.

In spite of the adverse socio-economic condi-
tions under which most of the Northern Plains
Indians live, the Public Health Service has found
a great deal of initiative among the Indian
groups in working toward a solution of their
health problems. Of the total of 36,900 bene-
ficiaries, 30,900 are served by directly operated

Public Health Service hospitals. The use of serv-
ices by this latter group has remained about con-
stant during the period fiscal year 1952 through
1956 but showed a pronounced increase in 1957.

1952

1953

1954

1955

1956

1957

8 PHS operated Indian
general hospitals

6,245

6,914

6,290

6,010

6,808

8,522

1 PHS operated

tuberculosis hospital

189

204

298

287

462

410

In this same group, outpatient therapeutic vis-
its in 1955 totaled 62,896; in 1956, 74,824; and
in 1957, 79,897. Outpatient preventive visits in
1955 totaled 11,624; in 1956, 16,694; and in 1957,
31,942.

In conclusion, one can say that the Northern
Plains Indians have too high an incidence of
preventable diseases, that they live under ad-
verse socio-economic conditions, but that thev
do use medical services and have an interest in
participating in the development of a more ef-
fective health program.

For those interested in Indian health in more detail,
reference is made to: Health Service for American In-
dians, Public Health Service Publication No. 531. For
sale by the Superintendent of Documents, U. S. Gov-
ernment Printing Office, Washington 25, D. C. Price
$1.75.

»

Lack of medical knowledge is less to blame for errors in diagnosis than lack
of judgment, alertness, and thoroughness. The factors most commonly respon-
sible for avoidable diagnostic errors are, in order of frequency: (1) failure

to carry out or repeat necessarv procedures; (2) neglect of symptoms or signs;
(3) failure to account for abnormal laboratory, electrocardiographic, or roent-
genographic reports; (4) attributing symptoms to the wrong condition, usually
a previously diagnosed illness; and (5) failure to make admission screening
tests.

In almost half of misdiagnoses, the history is not obtained from the patient
himself, usually because of alcoholism, confusion, weakness, shock, coma, or
aphasia. Alcoholism is implicated in 28 per cent of diagnostic errors; mislead-
ing normal roentgenograms in 12 per cent.

Infections, particularly bacterial pneumonia, meningitis, and bacterial en-
docarditis, are most frequently overlooked. Neoplasms, especially of the liver
and brain, are almost as frequently missed. Abdominal disorders requiring sur-
gery, especially those due to duodenal ulcer, and cardiovascular accidents are
common sources of error.

A studv of 1,106 autopsies showed that diagnoses were incorrect in 6
per cent.

Robert II. Gruver, M.D., and Edward D. Fheis, M IL, Veterans Administration Hospital, Wash-
ington, D.C. Ann. Int. Med. 47:108-120, 1957.

110

THE JOURNAL-LANCET

CtiHCCt iVlitorial

Health Supervision of Children

\ campaign to encourage regular periodic
health examinations of children has been
instituted by the National Congress of Parents
and Teachers. This has been recommended by
Dr. Henry F. Helmholz, national chairman of
the Committee on Health of the Parent-Teachers
Association, and an advisory committee repre-
senting 20 organizations concerned with child
health. In an editorial in the Journal of the
American Medical Association on May 4, 1957,
Dr. Helmholz outlines the recommendations
which have been made. He tells how this is an
outgrowth of the “summer roundup, which was
begun by the National Congress of Parents and
Teachers in 1925, to have all children receive a
medical examination before entering the first
grade in school.

The present recommendation is to extend this
I medical supervision to include regular yearly
health appraisal of children through the grades
and high school. This examination is to be per-
formed by the physician and dentist who nor-
mally serve the child or family. Continuing
health supervision is also recommended for in-
fants and preschool children. The latter would,
of course, be done more frequently than at yearly
intervals. Immunizations should be carried out
and booster shots given as needed. If symptoms
or screening tests indicate anything suspicious of
visual or hearing defects, appropriate consulta-
tion should be obtained. Any family or personal
emotional problems should be discussed with
the pediatrician or general practitioner who
should appraise the case and arrange for pscho-
logic or psychiatric care if a case should require
this type of evaluation or treatment. Diet and
vitamins are to be discussed at these examina-
tions, together with a brief discussion of normal
physical and mental growth and behavior. In
this day of television and many other distracting
influences, it is always well to mention the desir-
ability of limiting the time allowed for such
activities, together with a recommendation as to
the amount of rest needed at different age levels.

Officials of the P.T.A. throughout the country
have been notified of the recommendations of
the national organization and have been asked to
support such health supervision. Physicians con-
cerned with child care in each community are
encouraged to take the initiative in instigating
such a program in case it has not already been
done by the P.T.A. Physicians and the local
P.T.A. organization can work in cooperation with
each other to good advantage. The importance
of having this type of examination done by a
private practitioner whenever possible should be
emphasized to the P.T.A. members. A misunder-
standing in our local community in past years
led the P.T.A. to mistakingly inform parents that
the “summer roundup” examination had to be
done by the city health officer rather than the
family pediatrician or general practitioner. That
situation has since been corrected, but closer
cooperation between interested parties could
have prevented such a misunderstanding. The
health officer and public health nurse are an
integral part of the over-all program of child
health, but their services should be reserved for
cases in which financial or other reasons make
private care impossible. I am sure that most
health officers would agree that they cannot pos-
siblv examine all school children adequately and
that this should be done by the family’s own
physician wherever possible.

In conclusion, the national Parent-Teachers
Association stands ready to cooperate with local
physicians and their state and county medical
societies to promote better and more regular
health care of children. As physicians, it is our
responsibility to accept this challenge and offer
our full support and cooperation, recognizing
that this is simply putting emphasis on a practice
which most physicians have been carrying out as
a matter of course.

Laurence G. Pray, M.D.

Fargo, North Dakota

North Dakota State Chairman,

American Academy of Pediatrics

MARCH 1958

111

Etiologic Factors in Renal Lithiasis,
by Arthur J. Butt, 1956. Spring-
field, Illinois: Charles C Thomas,
20 contributors, 18 chapters, 387
pages. $12.50.

This book is a resume of the etio-
logic factors in renal lithiasis. The
historic review and the discussion
of the upper urinary tract obstruc-
tion and stasis are excellent. The
remaining 16 chapters deal with
anatomy and the metabolic, geo-
graphic, chemical, and infectious
theories in the production of stone.
There are sufficient illustrations of
good quality. Several minor typo-
graphical errors are present. The
bibliography is adequate. However,
this text is of value primarily to
those engaged in the investigation
of renal lithiasis.

M. P. Reiser, M.D.

•

Atomic Energy in Medicine, by K.
E. Halnan, M.D. General editor,
1). Wraoge Morley, 1957. New
York: Philosophical Library. 15 s.
This very readable book of 150
pages accomplishes to a remarkable
degree what its author indicates in
the foreword that he hopes it will
do; namely, to provide an account
of atomic energy in medicine intel-
ligible for persons without intensive
prior knowledge either of physics or
of medicine. It provides an ade-
quate account of the historic de-
velopment and a simplified state-
ment of the present status of knowl-
edge of atomic physics, which can
be verv valuable to physicians whose
formal education was completed
before 1940 and, therefore, did not
include much modern atomic theo-
ry. The book also presents a very
interesting treatment of the rationale
of the use of isotopic tracers in med-
ical research and diagnostic prob-
lems. It uses illustrative instances
to elucidate principles, rather than
attempting an exhaustive factual
treatment of the subject. An un-
usual feature of the book is a final
chapter on The Future. In it, the
author describes some newer re-
search approaches that have not as
yet led to anv useful results, but
which seem to him to hold prom-
ise. For example, “neutron-capture
therapy,” in which slow neutrons
which themselves have little biologic-
effect are “captured” with subse-
quent release of alpha rays of high
biologic activity by elements which
can be highly concentrated in ma-
lignant cells by one or another
method. Another new line of ap-
proach is through radiosensitizers of

which several types are known. The
discovery of such substances which
would be selectively concentrated
in malignant cells would provide
another possible approach to cancer
therapy. The author also predicts
great increases in the use of tracer
methods in medical diagnosis. In
these predictions, he stands on firm
ground because these methods are
already standard research labora-
tory procedures, and it is a virtual
certainty that a quarter of a cen-
tury hence they will be routine hos-
pital laboratory methods.

M. B. Visscher, M.D.

Clinical Pathology Data, by C. J.
Dickinson, B.S., B.M., M.R.C.P.
ed. 2, 1957. Springfield, Illinois:
Charles C Thomtis, 91 pages.
$4.00.

This is not a textbook but a refer-
ence book listing the normal and
pathologic alterations in all types of
clinical laboratory procedures. The
book is set up in tabular form and
covers all aspects of clinical pathol-
ogy, including physical properties of
blood and plasma, tests of blood
coagulation, red and white cell
measurements, blood chemistry, cere-
brospinal fluid, urine, feces, porphy-
rin metabolism, serologic tests for
syphilis, and adrenal, liver, and renal
function tests. The volume will be
of value to the medical student and
to many general practitioners whose
association with some of the tests is
sufficiently infrequent to necessitate
a review of normal and pathologic-
values.

John I. Coe, M.D.

•

Bedside Diagnosis, by Charles
Seward, M.D., F.R.C.P., ed. 4,
1957. Baltimore: Williams and
Wilkins Co., 420 pages. $5.00.
This handy little volume is written
for the physician who desires a
ready source of recall. Division
into 24 chapters is made in order
to consider prominent symptoms and
signs. There is a chapter on psy-
chogenic symptoms and six chapters

on pain, including one on some gen-
eral considerations. Chapters are
included on hematemesis, hematuria,
hemoptysis, and hemorrhagic dis-
eases. The character of approach to
each grouping might be illustrated
by chapter 16 on dyspnoea, cover-
ing 22 pages and divided into phys-
iology, the diagnostic approach,
causes of respiratory tract and lung
diseases, cardiovascular lung states,
blood states, and causes of central
nervous system diseases. The psy-
chogenic causes are listed as hys-
teria and effort syndrome. Chapter
17 considers tachycardia, but the
reviewer could find nothing on bra-
dycardia. Normal values, found in
chapter 24, are not covered as ex-
tensively as is the case in most
American hospitals. The author does
not attempt to give attention to spe-
cific disease per se but only to the
signs and symptoms pointing to
them. The work is rather brief and
tends toward minimal rather than
to extensive discussion. For this rea-
son, it should be of value to the
“busy physician” whose time for
study is limited.

S. Marx White, M.D.

•

The S' alien! Points and the Value of
Venous Angiocardiography in the
Diagnoses of the Cyanotic types of
Congenital Malformations of the
Heart, by Benjamin M. Gasul,
M.D., Gershon Hait, M.D., and
Egbert H. Fell, M.D., 1957.
Springfield, Illinois: Charles C

Thomas, 80 pages. $3.50.

This text presents the results of the
studies of 421 venous angiocardio-
grams without the use of information
from the history, physical, fluoro-
scopic, roentgenologic, electrocardio-
graphic, cardiac catheterization, or
autopsy findings. Diagnosis was
based on angiocardiographic findings
and the knowledge that the patients
were cyanotic.

On the basis of the results of these
studies, patients with cyanotic con-
genital heart disease were divided
into 4 entities: group I, entities in
which diagnosis can almost always
be made by proper interpretation of
technically good angiocardiograms,
group II. entities in which diagnosis
can usually be made; group III, en-
tities in which diagnosis usually can-
not be made; and group IV. entities
which always require additional
studies.

As the authors state, “this manu-
script represents only a summary of
the basic findings of the most im-

( Continued on page 26A )

112

THE JOURNAL-LANCET

“an ideal compound

for use in common
urinary tract infections .”*

Azo Gantrisin provided “prompt and effective clearing of
organisms and pyuria”* plus “dramatic relief of bladder and
urethral symptoms”* in 221 (97%) of 228 patients with
urinary tract infections.

Azo Gantrisin is particularly useful in the treatment of cystitis,
urethritis and prostatitis. It is equally valuable following uro-
logic surgery, cystoscopy and catheterization because it pro-
vides effective antibacterial action plus prompt pain relief.

AZO GANTRISIN®— 500 mg Gantrisin (brand of sulfisoxazole) plus
50 mg phenylazo-diamino-pyridine HC1

*F. K. Garvey and J. M. Lancaster, North Carolina M. J., IS: 78, 1957.

AZO GANTRISIN hoc.

HOFFMANN-LA ROCHE INC • NUTLEY 10 • NEW JERSEY
ORIGINAL RESEARCH IN MEDICINE AND CHEMISTRY

25A

BOOK REVIEWS

(Continued from page 112)
portant types of congenital malfor-
illations of the heart. ’ No other in-
formation, such as that obtained
from electrocardiograms, is included.

Ten basic malformations are pre-
sented with excellent, concise sum-
maries of gross pathology, hemody-
namics, and salient angiocardio-
graphic features. Diagrams and
photographs are very clear and in-
structive. Thus, one purpose of this
book, “to bring out the salient points
in the angiocardiographic diagnosis
of the various cyanotic types of con-
genital malformations of the heart.”
is well accomplished. The overlong
title could well be shortened to
“Handbook of Angiocardiography in
Cyanotic Congenital Heart Disease.”

The other purpose of this text, “to
establish the value of angiocardio-
graphy as a diagnostic tool tor these
entities,” confirms the experience of
various cardiac centers where the
use of angiocardiography in right to
left shunts is nearly routine. How-
ever, the history, physical examina-
tion, roentgenograms, fluoroscopy,
electrocardiograms, and physiologic
studies often are equally important
considerations. Thus, angiocardio-
graphy will rarely be used as a

“separate laboratory tool” as it is in
this study.

The percentages of correct diag-
noses from the studies of angio-
cardiograms alone are excellent,
especially in group I. It is feasible
that biplane angiocardiography at 6
to 12 frames per second will en-
hance the number of correct diag-
noses in all groups.

Since some centers are performing
selective angiocardiography with
mild sedation and without anesthesia,
it is likely that correct diagnoses will
be further increased with very little
added risk to the patient. This should
be especially true in groups III and
IV.

This handy, concise study should
be of very real value to the student
of congenital heart disease.

John P. Veit, M.D.

Psychiatric Education and Progress,
by John C. Whitehorn, M. D.,
1957. Springfield, Illinois: Charles
C Thomas, 45 pages. $1.75.

This small book contains the 1955
Salmon Lectures of the New York
Academy of Medicine. Doctor White-
horn, in his well earned capacity as
spokesman for the psychiatric pro-
fession, takes a critical, although

temperate, look at the present status
of postgraduate education for the
specialty of psychiatry. In approxi-
mately forty minutes reading time,
a remarkably clear opinion can be
obtained of the past and present
state of things in this field. While
acknowledging progress, he wisely
points to the numerous problems
ahead with particular reference to
psychoanalysis and to psychiatric re-
search and training for it. Because
of the phenomenal impact the men-
tal sciences have started to make on
medical education in general, these
lectures should be read by anyone
interested in this topic.

Donald W. Hastings, M.D.

•

The Chronically 111, by Joseph Fox,
1957. New York: Philosophical
Library, Inc., 229 pages. $3.95.
Joseph Fox is the executive director
of the Home for the Chronic Sick in
Irvington, New Jersey. He has writ-
ten a book of much interest to the
physician, the social worker, the
hospital administrator, and to people
interested in labor and management.
There is much valuable information
on rehabilitation and the social prob-
lems of the chronically ill.

Walter C. Aivarez, M.D.

for the peak of analgesic efficiency

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‘Subject to Federal narcotic regulations
Dilaudid®, E. Bilhuber, Inc.

2fiA

SERVING THE MEDICAL PROFESSION OF MINNESOTA,
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

FOREWORD

Another series of papers of special interest to those interested in the control of
tuberculosis and related conditions are appearing this spring in the Journal-
Lancet. The distinguished Wisconsinite, Dr. William S. Middleton, who now
heads the Medical Division of the Veterans Administration, emphasizes the point
recognized since ancient times that even today the personal relationship between
patient and physician plays a verv important role in the recovery of the patient
in such diseases as tuberculosis where specific drugs are available. The appro-
priate title is “Not by Bread Alone.”

The difficulties of tuberculosis eradication among human beings will be evi-
dent from the paper by the veterinarian. Dr. Paul S. Dodd of Illinois, on the
tuberculin test as it applies both to use among cattle and in human beings. In
some states, there is evidence of slight loss of ground in the bovine tuberculosis
eradication program, which theoretically would seem so easv to bring to a suc-
cessful conclusion.

There is increasing interest in the problem of radiation effects throughout this
country and, indeed, throughout the entire world, as evidenced bv recent corres-
pondence I have had from all corners of the globe. The paper on this subject by
Doctors Marvin, Loken, and Mosser, Department of Radiology, University of
Minnesota School of Medicine will be of special interest. Although further data
may cause some revamping of our current thinking, it would appear that the
radiation dosage from the ordinary Tlx 17-in. film, or even from taking a photo-
fluorograph, is so low that the possibility of genetic mutations of any significance
is remote. This probably also applies with regard to possible adverse effects due
to the direct radiation itself. These comments, of course, are with the assumption
that the machines are properly equipped with cones and filters to eliminate any
unnecessary stray radiation, have been checked by trained x-ray technicians, and
are being operated by trained personnel who are aware of hazards of radiation.
The current concern with regard to this problem does mean, however, that care-
ful records must be kept to determine the fruitfulness of chest x-ray screening of
various population groups which do not yield a significant number of new cases
of tuberculosis and other chest pathology and with priority given to the more
fruitful groups.

Finally, a tribute will appear to one of the pioneers in the voluntary tubercu-
losis field, Dr. Edward A. Meyerding, who is completing this spring thirty-four
years as the chief executive of the Minnesota Tuberculosis and Health Associa-
tion. The manv readers who have known him will join with Dr. Myers in express-
ing appreciation to Dr. Meverding for his many years of devoted service and in
extending him all good wishes for the future.

James E. Perkins, M.D.,

Managing Director ,

National Tuberculosis Association

Ionizing Radiation in Medicine

A Useful Tool and a Hazard

JAMES F. MARVIN, Ph.D., MERLE K. LOKEN, Ph D., and
DONN G. MOSSER, M.D.

Minneapolis, Minnesota

The advent of the atomic age with its mani-
fold increase in resources relating to ionizing
radiations has made it necessary to re-evaloate
the uses of radiations from all sources— x-rays, ra-
dium, radioisotopes, and atomic energy. This has
required a review of the usefulness versus exist-
ing or potential hazards of radiations in medi-
cine, dentistry, industrial development of atomic
power, and weapon testing programs. When
these uses of ionizing radiations were first eval-
uated, statements appeared to the effect that no
radiation hazard problem existed. The pendu-
lum of thought has now swung in the other
direction with its statements that fallout is peril-
ing all future generations, medical x-rays are
producing genetic damage, chest x-rays for tu-
berculosis case finding are extremely dangerous,
and that x-ray shoe-fitting machines are injuring
our children.

We cannot accept without proper interpreta-
tion either the statement that no radiation haz-
ards exist or the hysteria concomitant with theo-
ries that ionizing radiations have no place in our
societv. We are now in the atomic age and are
utilizing the increased resources with a limited
increase in radiation burden. It is not possible
to outlaw the use of atomic energy and all other
sources of ionizing radiations. We must recog-
nize that man cannot have multiple radiation
histories, so that any activity utilizing ionizing
radiations which increases the radiation exposure
to man will have repercussions on all other uses
of such radiation. All sources of ionizing radia-
tion thus relate to the present and future gener-

james f. marvin is associate professor of radiology
at the U niversity of Minnesota, merle k. token is
assistant j)rofessor of radiology at the University.
donn g. mosser is associate professor of radiology
and director of radiation therapy at the University.

Presented in part at district medical meetings in
North Dakota and at Concordia College, Moorhead,
Minnesota, sponsored by North Dakota Tuberculosis
and Health Association.

ations of man. Evaluation of the radiation haz-
ard must also include the problem of the health
and well-being of the individual, as well as ge-
netic considerations relating mankind’s future.

Anv regulations, code, or legislation adopted
for control of the radiation hazard cannot neglect
any possible sources of ionizing radiations. Safe
rules of conduct must include: (1) medical and
dental x-rays, radium, and radioisotopes (now
used much more generally than in the past) and
radiations for industrial purposes insofar as
these contribute to the irradiation of man, (2)
devices such as shoe-fitting Huoroscopes, tele-
vision, and electron microscopes, which may be
sources of ionizing radiation, and (3) atomic
energy for research, weapon testing, or power
( including the mammoth radioactive waste dis-
posal program).

BACKGROUND OR UNCONTROLLABLE RADIATION

All of us continuously receive radiation, termed
background or unavoidable radiation, from cos-
mic rays descending upon us from outer space
and from natural radioctivity in the earth, in our
building materials, and in our bodies. Fallout
from atomic weapon testing and contamination
from the use of radioactive materials may in-
crease the background or unavoidable radiation
in a particular area to such an extent as to be
considered dangerous.

Radiation exposure of an individual may origi-
nate from both external and internal sources. In
most instances, exposure from external sources,
principally x- and gamma rays, constitutes the
greater hazard. Radioactive materials contained
within the body constitute a greater hazard than
when they are external sources because of the
continuous irradiation of tissues surrounding
them. Some of the radiations emitted by radio-
active materials cannot penetrate sufficients to
be as serious a hazard as external sources but
will be absorbed in vital tissues when the mater-
ials are internal sources. Also, some radioactive
materials when taken internally are deposited

114

THE JOURNAL-LANCET

permanently in the bone as radium226 or stron-
tium90.

The problems associated with the weapon test-
ing programs of both the United States and
Russia can be appreciated if one considers the
reports which indicate seasonal and generally
increasing levels of radioactivity in our rainfall
and surface waters and reports which indicate
generally rising levels of strontium90 in bones
as found at autopsy. The problems associated
with increasing utilization of atomic energy for
power purposes can also be appreciated if one
considers the quantities of radioactive wastes
produced per year, those expected to be pro-
duced per year in the future, and the recorded
accidental release of radioactivity in event of
failure of an atomic power system. The recently
recorded uranium fire in the British power
reactor at Windscale, in which radioactive pro-
ducts (Iodinel31 was the major offender) were
released over a populated area, is an example
of the type of accident that has caused attention
to be focused on the problems of safe operation
of such reactors and civil liability in event of
accident.

Industrial and research programs employing
radiations do not deliberately employ man as the
test object, but rather attempt to plan operations
to avoid irradiations of man. On the other hand,
medical use of ionizing radiations involves direct
and planned use of ionizing radiations on man.
Control of the radiation hazard is, therefore, a
medical necessity, since this use of radiation has
made and is making a vital contribution to man’s
health and longevity but retains equally well the
possibility of detrimental effects on his health
and longevity, as well as its potential effects on
future generations.

BIOLOGIC EFFECTS

Effects of ionizing radiation may be manifested
in many ways, depending on the biologic sys-
tems involved and the factors governing the ex-
posure. Within months after Rontgen’s momen-
tous discovery of roentgen rays in 1895, pioneers
in roentgenology, such as Dodd, developed se-
vere dermatitis and submitted to first attempts
at skin grafting for control of the skin lesions.1
Daniel reported in 1896 a case of epilation fol-
lowing an attempt to demonstrate a metallic for-
eign body in the skull.2 One of Edison’s assist-
ants, Clarence Dally, became the first known vic-
tim of x-rays, dying from “x-ray cancer.”3 Radia-

Itions from radioactive materials were shown to
produce many of the same effects. The death of
Madam Curie, Nobel prize winner in nuclear
chemistry, has been attributed to the effects of

radiation. Development of cancerous lesions on
the fingers resulting from holding dental film in
the patient’s mouth during exposure has been
too common an occurrence among dentists, par-
ticularly those who entered dental practice be-
tween the years 1919 and 1927.

The increased incidence of leukemia among
radiologists is well documented.4"’' Other reports
indicate a higher incidence of abnormalities in
children of radiologists than in offspring of other
physicians.6 Radiation exposure is considered the
insidious common denominator in these and
other such studies.7 8

The biologic changes ascribed to radiation ex-
posure are initiated by the absorption of radiant
energy. This radiation may interact with atoms
of a biologic system to produce ionization, lead-
ing to disruption of molecular bonds and forma-
tion of highly oxidative radicals. Since the main-
tenance and growth of biologic structures are
dependent upon a multitude of chemical reac-
tions, which must be maintained in delicate bal-
ance, the absorption of radiant energy leads to
a change in this balance with ultimate modifica-
tion or destruction of the system. The ultimate
effect has been shown to depend on the dose of
radiation delivered, the time involved in its de-
liverv, and the type and energy of the radiation.
The spatial distribution of the ionization is also
a factor.

Since Muller’s experiments with Drosophila
thirty years ago, it has been known that ionizing
radiations increase the gene mutation rate. The
genes of mice have been shown to be 15 times
more sensitive to radiation induced mutations
than are those in Drosophila. Evidence of gene
mutations in human beings obtained in Japan
after the atomic blasts in Hiroshima and Naga-
saki indicates that radiation-induced mutation
rates in human beings appear to be close to those
observed in mice. Mutations in the germ cells
of the gonads are considered the most important
factor in determining the effect of radiation be-
cause of the involvement of future generations.
Furthermore, all mutations appear to be dele-
terious as has been observed in experiments with
fruit flies, various experimental animals, and in
cases of accidental exposure to man. On the basis
of fruit flv data, the most frequent mutations are
expected to cause minor impairments of body
function rather than gross changes. These ef-
fects include increased susceptibility to disease,
shorter life expectancy, and reduced fertility.

There is evidence that partial recovery from
the effects of radiation is possible. However, in
the case of genetic damage, most investigators
agree that these effects are cumulative. Genetic

APRIL 1958

115

damage is an example of a nonthreshold re-
sponse for which there is no recovery, and any
dose is damaging. Threshold effects require some
definite dose before observable changes occur
and generally some recovery from damage is
shown (figure 1).

DOSE OF IONIZING RADIATION

Fig. 1. Threshold versus nonthreshold phenomena.

UNITS FOR MEASUREMENT OF RADIATION

Radiation quantity can best be expressed in
terms of absorbed dose in ergs per gram of tis-
sue. Because of the difficulty in measuring en-
ergy absorption directly, several units have been
introduced. The roentgen (r) is the unit of
radiation exposure that was accepted in 1938,
indicating the amount of x- or gamma radiation
required to produce a definite quantity of ion-
ization in air under a particular set of conditions.
As ordinarily defined, 1 r of x-rays produces 87
ergs per gram of air or 93 ergs per gram of
water equivalent tissue. With the advent of the
medical use of radioactive isotopes, another unit,
the roentgen-equivalent-physical (rep), was de-
fined to include ionization resulting from alpha,
beta, and other radiations. This unit matched
the roentgen in terms of energy absorption in
tissue but lacked some of the limitations imposed
by definition on the roentgen. The rep has now
been replaced by the rad, which is defined as
the absorbed dose of radiation equal to 100 ergs
per gram of tissue.

The energy absorption in terms of ergs per
gram varies with the source and energy of the
radiation as well as the nature of the tissue. At
photon energies of 1 million volts (1 Mev)— the
average x-ray energy from a 2 to 3 million volt
x-ray machine or the energy from a cobalt tele-
therapv unit— the energy absorbed in ergs per

gram per roentgen of exposure is approximately
92 for muscle, 86 for fat, and 85 for bone. At
photon energies of 50,000 volts (50 Kev)— the
average x-ray energy from a 100 kilovolt x-ray
machine— these figures become 90 for muscle, 58
for fat, and 4(X) for bone. Other values may re-
sult from the use of equivalent roentgens of
other types of radiation, such as alpha, beta, neu-
tron, and so forth. Energy absorption in the vari-
ous tissues is thus expressed adequately in terms
of rads, whereas the roentgen is not a suitable
unit for this purpose.

Because the biologic effect on a particular ani-
mal, organ, or system may not depend directly
on the energy expended in the tissue for the
different types of radiation, another term, the
rad-equivalent-man or mammal (rem), has been
defined. The rem is the product of the dose in
rads and a term known as relative biologic ef-
fectiveness (RBE). The RBE must be measured
directly in terms of the effect of one type of ra-
diation on a particular system compared to the
effect of x-rays of known energy or, as is now
preferred, to the effect of the gamma rays of
either radium226 or cobalt60. Thus, the RBE is
a biologic unit, which may have different values
for the various organs of the same animal. Like-
wise, the rem is a biologic unit. Fortunatelv, the
RBE is 1.0 or very close to 1.0 for the x-rays and
gamma rays which are of the greatest impor-
tance in clinical medicine.

PERMISSIBLE LIMITS OF RADIATION
DOSE TO MAN

It is difficult to assay the harmful effects of
small doses of radiation. A base line can be es-
tablished using measured values of background
radiation. The average exposure is considered to
be of tbe order of 3 millirems per week or 5
reins per generation (from conception to age
30). This background radiation increases with
altitude and may be higher in some locations,
such as parts of Sweden, where radioactive ele-
ments in building materials result in values as
high as 8 millirems per week.9

Genetic evidence indicates there is no safe
dose of radiation.10 Thus, it becomes necessary
to balance the genetic risk against the benefits
derived from the various uses of radiation. A
National Academy of Science report estimates
that 30 to 80 r constitutes a “doubling dose,"
that is, this dose will double the spontaneous
mutation rate.11 On this basis, this report in-
cludes a recommendation that the maximum per-
missible dose (MPD) be set at 10 r to the go-
nads during the prereproductive lifetime of the
population. If 50 r is then accepted as the av-

116

THE JOURNAL-LANCET

erage doubling dose, a population receiving an
average of 10 r will show a 20 per cent increase
in gene mutation rate. This represents an ex-
pected increase in abnormalities in offspring at-
tributable to genetic mutation from the normal
incidence of 2 to 2.4 per cent.12 Although these
estimates are based on data derived from ex-
periments with fruit flies and mice, evidence
indicates that the data may also be valid for
human beings.

The National Committee on Radiation Protec-
tion (NCRP) has recommended that the MPD
of 0.3 rems per week, which was accepted prior
to February 1957, be reduced.13 This committee
recommended that the MPD be set at no more
than 0.3 rems in any one week, with a limit set
at 3.0 rems in any thirteen-week period and a
further limit set at 5 rems per year. For the pop-
ulation at large, a lower limit was recommended
of 0.5 rems per year, which is a factor of 10
below the “occupational exposure” levels. This
latter recommendation has been published in
terms of a gonadal dose to the whole population
now to exceed 14,000,000 rems per 1,000,000 peo-
ple from conception to pubertv, which would
average approximately 0.5 rems per year.

CONTROL OF RADIATION

Radioactive fallout. Background radiation for
all individuals in a given area may increase as
a result of weapon testing, atomic power plant
failure, or faulty waste disposal programs. This
will lead to increased quantities of external ra-
diation and to an increased probability of in-
gestion of radioactive materials. This situation
has now been shown to exist in a large part of
the United States and, particularly, the upper
Midwest as a result of radioactive fallout from
nuclear weapon testing.

The Minnesota Department of Health has just
released data on tests of Minnesota’s surface wa-
ters, which indicated that during the entire sum-
mer and early fall of 1957, levels of radioactivity
in Minnesota’s rainfall and in the surface waters
exceeded the maximum permissible concentra-
tion ( MPC ) of mixed fission products as estab-
lished in the National bureau of Standards
(NRS) Handbook 52 (values of MPC as given
must be altered in accordance with present
MPD).14 The data released do not constitute
evidence that a real hazard exists but only that
utilization of atomic energy in weapon testing
does result in a real and measurable increase in
background radiation. Knowledge of the in-
crease in radioactivity to the levels shown con-
stitutes a mandate that studies be initiated and
maintained to evaluate the hazard in terms of

concentrations of particular radioisotopes. The
studies must indicate whether or not removal of
these isotopes from drinking water is necessary
and must warn of any future increases in levels
of radioactivity.

Radioisotopes. Radium and thorium and their
products have been the radioactive materials
most commonly used in medicine. In the past,
radium has very often been stored in the office
safe in the hospital or office. This practice is a
violation of all rules of radiation safety.

Radioactive isotopes are now being used in
medicine for such purposes as diagnosis and
treatment of thyroid disease (1131), measure-
ment of blood (plasma) volume (1131 labeled
human serum albumin), measurement of red
cell volume and survival (Cr51), pernicious ane-
mia (Co60 labeled vitamin B12), tumor detec-
tion and treatment of blood dyscrasias (P32),
cardiovascular studies (1131, Na24), and metab-
olism of elements (P32, Na24, Ca45), or of la-
beled organic materials (S35, C14).

The relative hazard of the radioisotopes de-
pends on the lifetime and site of deposition in
the body and on the energy and tvpe of radia-
tions (table 1). Certain isotopes, such as Sr90,
1131, and Fe59, are considered particularly dan-
gerous because they are readily metabolized,
concentrated in critical organs, and remain for
long lifetimes. Quantities of particular isotopes
(microcuries) permitted in the body, if present
MPD is not to be exceeded, are given in table 2.

Roentgen rai/s for diagnostic purposes. The
hazards associated with the use of x-rays for
diagnostic purposes may be considered in 3
major categories: (1) equipment, (2) protective
devices, and (3) safety habits. Tables 3, 4, and
5 summarize recommendations for the control
of hazards in fluoroscopy and radiography. This
information was derived primarily from the spe-
cifications of the NCRP listed in NBS Handbook
60 on “X-rav Protection.”

Fluoroscopv presents the greatest potential
radiation hazard among the various diagnostic
procedures in which x-rays are used because of
the time that may be involved. If the precau-

TABLE 1

FACTORS DETERMINING HAZARD FROM RADIOISOTOPES

1. Quantity of material used.

2. Bodv retention.

3. Radiosensitivity of tlie involved tissues.

4. Relationship of involved tissues and or-
gans to body function.

5. Effective half life of the isotope.

6. Energy and character of the emanations.

APRIL 1958

117

TABLE 2

MAXIMUM PERMISSIBLE CONCENTRATIONS OF SOME RADIOISOTOPES IN THE BODY

Element

Emission

Site of
localization

Effective half
life (days)

MPC°

( microcuries)

Ra-26 + K dtr.
product

alpha

bone

1.6 x 101 2 3 4 5

0.03

Li (natural)

alpha

bone, lung, kidneys

30-120

0.003

Aulns

beta, gamma

kidneys

2.69

3.3

1131

beta, gamma

thyroid

7

0.1

Sr™

beta

bone

2.7 x 10»

0.3

Co60

beta, gamma

liver

9

1.0

Fe59

beta, gamma

blood

27

330

Cu4r>

beta

bone

151

22

S35

beta

skin

18

33

pa 2

beta

bone

14

3.3

Na24

beta

total body

0.61

5

C’4

beta

total body

130

250

“MPC is Based on MPD of 0.1 reins per week.

TABLE 3

FACTORS FOR CONTROL OF RADIATION EXPOSURE
IN FLUOROSCOPY

Fluoroscope

1. Maximum of 0.1 r/lir. /meter leakage radiation.

2. Cone and adjustable diaphragm to limit
the beam.

3. 2/2 mm. aluminum filter permanently fixed.

4. Target-to-table distance at least 18 in.

5. “High-low” milliamperage change over switch.

6. Cumulative timing device.

7. 1.5 mm. lead equivalent material in fluorescent
screen.

8. 10 r/min. maximum dose at the table top.

9. mm. lead equivalent drape during
horizontal use.

Protective devices

1. 1.5 mm. lead equivalent in doors and
walls to 7 ft.

2. Leaded aprons and gloves worn by flnoroscopist.

3. Radiation monitoring with film badges or pocket
dosimeters.

4. Leaded drapes overlying patient’s gonads when
possible.

Safety habits

1. Trained personnel.

2. Maximum utilization of inverse square law.

3. Small field size and limited time of operation.

4. Adequate dark adaptation.

5. No holding of patients.

6. Fluoroscopist’s hands (with gloves) not placed in
direct beam.

TABLE 4

FACTORS FOR CONTROL OF RADIATION EXPOSURE
IN RADIOLOGY

Radiographic machine

1. Maximum of 0.1 r/hr. /meter leakage radiation.

2. Cones or diaphragms to limit field size.

3. 2/2 mm. aluminum filter in medical units.

4. IK mm. aluminum filter in dental units.

5. Exposure meter to limit time.

6. Remote control switch operated from protected area.
Protection devices

1. 1.5-3 mm. lead equivalent in doors and walls to 7 ft.

2. Radiation monitoring recommended.

3. Leaded drapes overlying patient’s gonads when
possible.

Safety habits

1. Trained personnel.

2. Maximum utilization of inverse square law.

3. No holding of patients.

4. Use of lead drapes if patient attendance is neces-
sary.

5. Limit number of exposures by careful technic.

TABLE 5

FACTORS FOR CONTROL OF RADIATION EXPOSURE
FROM PORTABLE UNITS

1. Radiation monitoring is recommended.

2. Trained personnel.

3. No holding of patients or film cassette.

4. Lise of leaded aprons and drapes for patient and
operators.

5. Rotation of operators among various x-ray diag-
nostic units.

118

THE JOURNAL-LANCET

tions listed in the tables are observed, the radia-
tion to which the fluoroscopist and assistants are
exposed can be controlled well below present
MPD levels even for heavy schedules of work.
The use of old machines that do not adhere to
the specifications as listed by the NCRP may
be a real source of difficulty. Adequate shield-
ing in the tube housing and cone, shutters that
operate properly, and sufficient filtration are all
verv important in eliminating nnnecessarv ra-
diation exposure. The importance of using lead
aprons, gloves, and proper protective barriers
cannot be overemphasized. A means for peri-
odic radiation monitoring is also recommended.
This can be done simply and effectively without
great expense by using dental film, special moni-
toring film, or pocket dosimeters.

Actually, good safety habits are the most im-
portant factors in controlling radiation exposure.
Protection by distance (inverse square law),
limitation of the field size, control of time, ade-
quate dark adaptation, and avoidance of the
primary beam are all practices readily available
to the careful fluoroscopist. Scattered radiation
through the Bucky slot and from the patient and
table top leads to significantly higher dose rates
at the position occupied by the fluoroscopist dur-
ing horizontal fluoroscopy than during vertical
fluoroscopy. Therefore, an additional leaded
drape is recommended for use in horizontal flu-
oroscopy (table 3). Effect of field size and filtra-
tion on radiation levels at various points of inter-
est during fluoroscopy are shown in figure 2.

Even as fluoroscopes present the major haz-
ard to the operator, so these units also consti-
tute the greatest potential danger to the patient.
A dose rate of 10 r per minute is permitted at
the table top of a fluoroscope (table 3), so that
long periods of exposure result in a sizable pa-
tient dose. In a radiation hazard survey of flu-
oroscopes with no filtration and with a short
focal spot to table top distance, we have meas-
ured dose rates in excess of 35 r per minute at
table top. Under these conditions, the patient
may very well receive a dose sufficient to pro-
duce a sharp erythema. Bell has referred to the
patient hazard during fluoroscopy in an article
appropriately entitled “X-ray Therapy in Flu-
oroscopy.”13 He reported that under extreme
conditions, as during gastrointestinal fluoroscopy
at 80 kvp, 3 ma, with no added filter, that a
patient may receive a skin dose of 400 r and
a dose of 47.5 r at a depth of 10 cm. in the
tissues. A summary of measurements of patient
exposure under varying conditions of fluorosco-
py is shown in table 6. These measurements
serve to emphasize the importance of filtration,

control of time, and the limiting of field size to
keep the integral dose as low as possible.

In conventional, carefully executed radiogra-
phy, the operator is in little danger of radiation
exposure. Special technics, such as urography,
angiocardiography, cerebral angiography, and
aortography, which require the presence of a
physician and assistants in the radiographic
room, produce a potential radiation problem
that can be controlled by use of leaded drapes
properly placed, in addition to maintaining the
greatest possible distance from the x-ray beam.
A number of reports illustrate the pronounced
decrease in exposure to x-ray personnel that may
be effected by simple safety considerations. For
example, Ritvo and associates11’ reported that
with the use of proper coning, filtration, and
position, it is possible to reduce the dose to the
physician’s hands in urethrography from 66 mr
to less than 13 mr per exposure. Our own meas-
urements indicate exposure to the physician’s
hands during cerebral angiography can be re-
duced to 2 mr per exposure. If the hands ap-
proach the beam or if a larger beam is used,
the exposure increases 15 to 30 times. In fe-
moral arteriography and lumbar aortography,
a lead apron used as a drape can reduce the
exposure from 300 mr to less than 20 mr.

Photofluorographv deserves special mention
because of its use in extensive surveys for tuber-
culosis and certain hospital admission proce-
dures. Many of the older units were notoriously
hazardous for the operators. The majority of the
newer units have incorporated protective bar-
riers and remotely located switches for control-
ling exposure. Studies of this hazard have been
published by several authors.1718

Because of the confined areas in which these
units are operated, great care must be exercised
in placing the x-ray personnel in positions of
utmost safety. Small changes in location can
result in large differences in exposure. For this
reason, it has been recommended that a protec-
tion survey be made for all of these units.17 Fur-
thermore, it is recommended that personnel be
rotated among the various tasks assigned in this
survey program in order to keep the exposures
to any one group below the MPD.

Patient exposure from radiographic installa-
tions may reach hazardous levels if the filtration
of the machine is inadequate, if the primary
beam is not restricted by coning, and if the num-
ber of radiographs is not carefully controlled.
Average exposures for conventional radiographic
technics using x-rays filtered by 2 mm. of alu-
minum and with field size limited by cones or
diaphragms are summarized in table 7. These

APRIL 1958

119

Fig. 2. Effects of field size and filtration on radiation exposure in fluoroscopy

Fluoroscope 90 KV, 3 MA

Filtration , 1 mm. Al. n / 3 mm. Al.

’Id size

7x9

4x4 (in.)

7x9

4 x 4 ( in.)

A

12 r/min.

12 r/min.

7.2 r/min.

7.2 r/min.

B

.38 r/min.

.36 r/min.

C

4.2 mr./hr.

4.2 mr./hr.

4.0 mr./hr.

4.0 mr./hr.

D

550 mr./hr.

180 mr./hr.

400 mr./hr.

90 mr./hr.

E

240 mr./hr.

50 mr./hr.

200 mr./hr.

45 mr./hr.

F

450 mr./hr.

1 10 mr./hr.

200 mr./hr.

G

20 mr./hr.

15 mr./hr.

15 mr./hr.

12 mr./hr.

H

40 mr./hr.

19 mr./hr.

30 mr./hr.

17 mr./hr.

1

6 mr./hr.

6 mr./hr.

6 mr./hr.

6 mr./hr.

doses represent an average of our measurements
together with those reported by others.19-22

It may be seen that the skin dose to a pa-
tient’s chest is considerably higher in photoflu-
orography than in conventional 14 x 17 in. radio-
graphs of the chest. The average dose was found
to be about 750 mr, whereas, with the 14 x 17 in.
plate, the average dose was found to be 30 mr.
This represents about a 25-fold difference in
exposure. A corresponding difference in the
gonadal dose would be anticipated and has been

confirmed in the measurements reported by
Webster and Merrill.19

For exposures in which the gonadal dose
varies appreciably with sex, both values are
given. It is noteworthy that the use of a leaded
apron to protect the gonads for x-ray procedures
not involving this region permits reduction of
the gonadal dose by a factor of about 4. 2:1

Another diagnostic procedure involving un-
usual hazards to the operator is dental radiogra-
phy, in which exposures to the dentist may be

TABLE 6

PATIENT EXPOSURE IN FLUOROSCOPY

Exposure ( table top )
Skin close (5 min.)

Integral dose (5 min.)
10 x 10 cm. field

20 x 20 cm. field

Machine

No. 1 90 kv, 4 ma, i

No. 2 90 kv, 3 ma,

No. 3 image amplil
No. I
36 r/min.

180 r

52,000 gm.-r
(560 ergs)

208,000 gm.-r
(2,240 ergs)

i filter, fsd 15 in.

IK mm. Al., fsd 18 in.
with machine No. 2
No. 2
6 r/min.
30 r

17,300 gm.-r
( 186 ergs)

69,000 gm.-r
(743 ergs)

No. 3
1.5 r/min.
7.5 r

4,320 gm.-r
(47 ergs)

17,250 gm.-r
( 1 85 ergs )

120 THE JOURNAL-LANCET

TABLE 7

PATIENT EXPOSURE IN RADIOGRAPHY

AVERAGE EXPOSURE ( MILLIROENTGENS ) FOR CONVENTIONAL TECHNICS USING X-RAYS FILTERED HY 2 MM. AL.
AND WITH FIELD SIZE LIMITED BY CONES AND DIAPHRAGMS

Skin dose

Gonadal dose

Anatomy

View

(mr.)

(mr.)

Skull

AP

600

.02

Shoulder

AP

200

.02

Hand

120

.03

Chest

PA

30

.03

Chest ( P.R. ) *

PA

750

.75

Abdomen

AP

550

20 (150)**

G.l. series

PA

900

5 (50)

Lateral

2,000

10 (60)

Barium enema

PA

1,000

30 (200)

Lateral

2,500

40 (270)

Spine (lumbar)

AP

800

15 (150)

Lateral

2,300

40 (240)

Pelvis

AP

600

450 (150)

Lateral

2,000

1,500 (400)

Knee

AP

40

0,3

Foot

AP

20

0.2

0 PhotoHuorogram
00 Indicates gonadal dose t<

females

when significantly different

from males.

TABLE 8

PATIENT EXPOSURE

FROM DENTAL X-RAY UNITS

Doses to the skin:

65 kvp, 10 ma, .3 seconds

With added filter

Machine

No filter

With added filter

and fast film

No. 1

1.0 r

( M mm. Al. ) 0.66 r

0.22 r

No. 2

2.8 r

(2 )i mm. Al.) 0.7 r

0.24 r

No. 3

2.4 r

( 1 mm. Al. ) 1 .4 r

0.5 r

No. 4

2.4 r

(1 mm. Al.) 1.3 r

0.33 r

No. 5

4.0 r

(2 'A mm. Al.) 2.2 r

0.7 r

All machines properly coned.

Approximately ffd 14 in.

Maximum estimated dose to si

in for 14 exposures (full mouth

series)

With added filter

Machine

No filter

With added filter

and fast film

No. 1

9 r

6 r

2 r

No. 2

26 r

6.5 r

2.2 r

No. 3

22 r

13 r

4.7 r

No. 4

22 r

12 r

3.1 r

No. 5

37 r

20 r

6,5 r

Gonadal dose estimated per full mouth series
4-5 mr. 2 mr.

less than 1 mr.

Information obtained through courtesy of Dr. E. E. Peterson, University of Minnesota School of Dentistry.

as high as 1.5 r per hour of operation.24 The
practice of holding the film in the patient’s
mouth must be prohibited for reasons already
mentioned. The operator of a dental x-ray ma-
chine may receive a total body dose of 125 mr
per full mouth set of x-rays if care is not exer-
cised.

Exposures to patients from 5 dental units at

the University of Minnesota Dental Clinic are
summarized in table 8. These units were oper-
ated as installed and then with addition of
proper (maximum useable) filter and with the
usual medium speed and then with the fastest
film available. Proper coning of the beam was
utilized in all procedures. This table illustrates
the reduction which is readily possible in radia-

APRIL 1958

121

tion dose to the patient in dental radiography.

Ionizing radiations used in such devices as
shoe-fitting Huoroscopes are also directed de-
liberately at man. These units are x-ray ma-
chines, usually operated at 50 kvp, 3-8 ma, 7.5-
20 cm. focal-skin distance and with or without
the proper 1 mm. aluminum filter. These units
may or may not be adequately surrounded with
lead barriers for operator protection. The Min-
nesota State Department of Health surveyed 138
of these machines and found that the radiation
dose to the foot ranged from 0.4 to 23 r per ex-
posure with an average of 1.96 r. Radiation to
the operator ranged from 0 to 250 mr per hour
with an average of 10.5 mr per hour. In the
past, control of these machines has been under-
stood to mean adequate protection for the op-
erator, limited time of exposure (5 seconds),
dose to the foot per exposure not to exceed 1 r
and an annual limitation of 15 exposures per
foot (a very difficult number to control).25 At
the present time, the use of these machines is
prohibited in the Commonwealth of Pennsylva-
nia, in New York City, and in Minneapolis (by
ordinance). The American Medical Association
at its meeting in Philadelphia in December 1957
took a very strong stand to eliminate further use
of Huoroscopes for the fitting of shoes. At the
present time, any recommendation favoring con-
trol of these units rather than their elimination
would not appear to be in order.

Radiation therapy also carries a somatic and
genetic risk for the patient. When treating ma-
lignant disease, there can be no question that
the risk is justified. However, the use of x-rays
and radium in treating benign conditions, par-
ticularly those of the skin, such as acne, neuro-
dermatitis, hemangioma, and verucca of the
hands and feet, must be carefully limited to
conditions which cannot be effectively controlled
by other methods.

Radioactive isotopes for most clinical pur-
poses carry practically no radiation risk, except
in the presence of pregnancy. We feel that it is
desirable to withhold even small tracer doses of
radioisotopes in pregnancy because of potential
hazard to the fetus. There is some debate con-
cerning the relative radiation hazard when using
radioactive iodine to treat hyperthyroidism in
patients under 35 years of age. The hazard of
inducing thyroid malignancy is as yet theoretic
and must be balanced in the physician’s evalua-
tion against the known small but, nevertheless,
real hazards of other therapeutic methods. It
is unlikely that other properly conceived human
uses of radioisotopes will represent any real
hazard to patients.

KADIATION DIARY

How might one determine his exposure to radia-
tion over a period of months and years? For
individuals whose occupations require the use
of ionizing radiations, this problem is most ef-
ficiently handled by the use of film monitoring
badges or pocket dosimeters carried at various
parts of the body. The exposures received can
be logged for a continuous record. Many hospi-
tals are doing this routinely to safeguard the
health of their workers, as well as to provide
legal protection for the hospitals.

For the population in general, this task is
much more difficult, if not impossible, to carry
out satisfactorily. The NRCP has given thought
to this problem in order to assist the state health
departments in setting up specifications for the
control of radiation hazards.26 A radiation diary
to be carried by everyone from the cradle to the
grave has been considered. However, the prob-
lems in administering such a program are over-
whelming to say nothing of the added instru-
mentation and training required to make logical
estimates of gonadal doses for all exposures. For
example, there are some 100,000 diagnostic x-ray
units in operation in the United States with only
aborft 5,000 certified radiologists. Even among
this group of specialists, there would be consid-
erable difficulty in estimating gonadal doses or
even skin doses for all exposures.

SUMMARY

Ionizing radiations have in the past served a
verv important role in the medical advances re-
sponsible for the improved health and longevity
of our population. They have served equally well
in industry by contributing to our improved
living standards. All of us should be aware that
ionizing radiations may equally well constitute
health hazards. Unwiselv used, some increased
longevity and well-being may be sacrificed.

The medical profession has a moral responsi-
bility to keep the radiation dose at a minimum
compatible with good medical diagnosis and
therapy. Radiation dose should be known and
controlled for the patient, physician, assistants,
and general public. The use of ionizing radia-
tions for diagnostic purposes should not be a
substitution for careful physical examinations
and complete patient histories. The benefits of
ionizing radiations for therapeutic purposes
should be carefully weighed against the risks.
During the childhearing period, the utilization of
x-rays or administration of radioisotopes should
be more carefully controlled than in older pa-
tients. It may be desirable to completely elim-
inate the use of radioisotopes and to sharply

122

THE JOURNAL-LANCET

curtail the use of x-rays during pregnancy. Ra-
diographic rather than fluoroscopic examination
may be the diagnostic choice in studies of in-
fants and in most studies of the heart and lungs,
since one minute of fluoroscopic examination
results in a radiation dosage comparable to that
received from several hundred radiographs.

The medical profession must constantly strive
to improve its x-ray equipment so that required
studies can be performed with a minimum of
radiation. This implies at the present time the
use of adequate radiation barriers around the
x-ray tubes; adequate cones or diaphragms to
limit the size of the radiation fields; high speed
intensifying and fluoroscopic screens and film;
adequate filtration on all units, including porta-
ble x-ray machines; adequately protected con-
trol areas for the diagnostic and therapy ma-
chines; and use of suitable lead drapes, aprons,
gloves, and other protective devices.

Training in the use of ionizing radiations can-
not be overemphasized. Poor safety habits on

REFERENCES

1. Macy, I. A., Jr.: Walter James Dodd. Boston: Houghton

Mifflin Co., 1918.

2. Daniel, J.: The Depilatory action of the x-rays. New York

Med. Rec. 49:595, 1896.

3. Evans, W. A.: Science of Radiology, edited by O. Glasser.
Springfield, Illinois: Charles C Thomas, 1933.

4. Warren, S.: Longevity and causes of death from irradia-

tion of physicians. J.A.M.A. 162:464, 1956.

5. March, H. C.: Leukemia in radiologists in a 20-year period.
Am. J. M. Sc. 220:282, 1950.

6. Macht, S. H., and Lawrence, P. S.: National survey of

congenital malformations resulting from exposure to roent-
gen radiation. Am. J. Roentgenol. 73:442, 1955.

7. Murphy, D P.: Ovarian irradiation and health of the sub-

sequent child. Review of more than 200 unreported preg-
nancies in women subsequent to pelvic irradiation. Surg.,
Gynec. & Obst. 48:766, 1929.

8. Giles, A. M.: Pregnancy following pelvic irradiation. J.

Obst. & Gynaec. Brit. Emp. 56:1041, 1949.

9. Sievert, R. M., and Hultqvist, B.: Variations in natural

gamma radiation in Sweden. Acta radiol. 37:388, 1952.

10. Glass, B.: Genetic basis for limitation of radiation exposure.
Am. J. Roentgenol. 78:955, 1957.

11. Biological effects of atomic radiation. Washington, D. C.:
National Academy of Sciences. Nat. Res. Council, 1956.

12. Crow, J. F.: Genetic considerations in establishing maximum
radiation doses. Radiology 69:18, 1957.

13. Maximum permissible radiation exposures to man. National
Committee on Radiation Protection and Measurement. Radi-
ology 68:260, 1957.

14. Interim report on biological effects of radiation. Minnesota
Governor’s Committee on Atomic Development Problems.
February, 1958.

the part of the technician or the physician may
destroy all the benefits of the protective bar-
riers and devices in an x-ray department. The
presence of a technician or physician may be
required and desirable during an x-ray exposure,
but lack of protective aprons and gloves can
only be considered a very poor safety practice.

Cognizance of radiation hazards coupled with
good judgment and common sense27 will go a
long way in reducing the exposure of our whole
population to ionizing radiations for diagnostic
purposes. It is not unreasonable to expect that
with improvement in technic, radiation to the
general population from medical x-rays present-
ly estimated at approximately 5 r per thirty
years ( equal to the natural background ) may
be substantially reduced despite an increased
use of ionizing radiations in medicine. On this
basis, we believe that no significant genetic prob-
lems need be anticipated in future generations
as a result of the use of ionizing radiations in
medicine.

15. Bell, A. L. L.: X-ray therapy in fluoroscopy. Radiology

40:139, 1943.

16. Ritvo, M., D’Angio, G. J., and Rhodes, I. E.: Radiation haz-
ards to nonradiologists participating in x-rav examinations.
J.A.M.A. 160:4, 1956.

17. Van Allen, W. W.: Secondary radiation fields surrounding

photofluorographic equipment. Radiology 56:832, 1951.

18. Birnkrant, M. I., and Henshaw, P. S.: Further problems

in x-ray protection; radiation hazards in photofluorography.
Radiology 44:565, 1945.

19. Webster, E. W., and Merrill, O. E.: Radiation hazards.

II. Measurements of gonadal dose in radiographic examina-
tions. New England J. Med. 257:811, 1957.

20. Sorrentino, J., and Yalow, R.: Nomagram for dose deter-

minations in diagnostic roentgenology. Radiology 55:748,
1950.

21. Billings, M. S., Norman A., and Greenfield, M. A.:
Gonad dose during routine roentgenography. Radiology 69:
37, 1957.

22. Baily, N. A.: Patient exposure to ionizing radiation in dental
radiography. Radiology 69:42, 1957.

23. Laughlin, J. S., Meurk, M. L., Pullman, I., and Sherman,

R. S.: Bone, skin, and gonadal doses in routine diagnostic

procedures. Am. J. Roentgenol. 78:961, 1957.

24. Nolan, W. E., and Patterson, H. W.: Radiation hazards

from use of dental x-ray units. Radiology 61:625, 1953.

25. Safety code for the industrial use of x-rays. Am. Standards
Assoc., New York, 1946.

26. Regulation of radiation exposure by legislative means. Nat.
Bureau of Standards, Handbook 61, Washington, December,
1955.

27. Stone, R. S.: Common sense in radiation protection applied

to clinical practice. Am. J. Roentgenol. 78:993, 1957.

APRIL 1958

123

Injury from Blunt Trauma to the Chest:

Its Management in the Community Hospital

FRANK E. JOHNSON, M.D.

M inneapolis, Minnesota

A fall caused by tripping or slipping contin-
xY ues to supply each doctor’s practice with a
constant number of patients with chest injuries.
The great majority of such injuries are of a rela-
tively minor nature, such as abrasion or con-
tusion to the chest wall or simple rib or costal
cartilage fracture. The over-all incidence of chest
injuries, however, is increasing directly as the
modern automobile becomes faster, the modern
highway becomes smoother and straighter, and
activities of life become more mechanized. Tho-
racic injuries resulting from automobile accidents,
as from other sources of major trauma, commonly
represent only a part of the total body injury,
which may include a variety of fractures to the
extremities, injury to the abdominal viscera, and
serious head injury. By the nature of the organs
affected, however, thoracic trauma is often of
major importance in the total body injury and
demands prompt, effective treatment if life is to
be salvaged. The fact that the majority of these
serious chest injuries occur at places remote from
the large medical centers with their specialized
equipment and personnel prompts the writing
of this article. It is felt that earlv application of
certain simple technics, using equipment avail-
able in even the smallest hospital, will result in
salvaging the lives of a number of patients with
chest injuries who might otherwise be lost at
the local hospital or in transit to the medical
center.

Case 1. A 49-year-old white man suffered a severe
bilateral crushing injury of the chest when he was
caught under his tractor after it overturned. He was
admitted to a community hospital in western Minnesota
where he was treated with tracheotomy, bilateral inter-
costal catheter drainage of the pleural space, and blood
transfusions. Severe subcutaneous emphysema is to be
noted in figure la. It should be recognized as one sign of
an undrained pneumothorax. In itself this not harmful.
It is, rather, evidence of beneficial decompression of a
pneumothorax into the soft tissues. In figure lb, the final
radiologic result is evident. The patient continues to
work full time as a farmer.

frank e. johnson is clinical instructor in surgery at
the University of Minnesota.

MINOR CHEST INJURIES

Abrasion, contusion, and laceration. Of the lesser
injuries, lacerations (after suture), abrasions,
and burns of the chest, as elsewhere on the body,
are best treated by the “open method” without
dressings, antiseptics, or ointments but with a
twice daily soap and water washing.

Simple fracture of rib or costal cartilage. For
the patient who complains of chest pain aggra-
vated by straining, bodily movement, deep
breathing, or coughing and who gives a history
of recent injury, a properly conducted physical
examination is the most reliable means of diag-
nosing a fracture of a rib or costal cartilage. Each
rib should be examined by exerting pressure on
it away from the area of injury and pain. The
motion caused at the fracture site by this ma-
neuver aggravates the patient’s pain and avoids
the confusing factor of soft tissue tenderness
when pressure is applied at the site of trauma.
The lower six ribs are counted and examined,
starting with the twelfth and proceeding cephal-
ad posteriorly. Because of the presence of the
scapula and heavy shoulder muscles posteriorly,
the upper ribs are best counted off and examined
anteriorly or in the axilla. Whereas, physical ex-
amination is most reliable in the diagnosis of a
chest-wall injury, the roentgenogram is essential
in the discovery of an intrathoracic injury. We,
therefore, omit roentgenograms for rib detail and
order instead routine upright posteroanterior and
lateral x-ray films of the chest for signs of intra-
thoracic disorder. In patients with simple rib
fracture, the routine chest x-ray film may be nor-
mal and, in such cases, the physician’s function is
to provide relief of pain and discomfort. In most
instances, the nonelastic canvas rib belt snugly
applied provides sufficient immobilization of the
fracture and consequent relief of pain, so that
respiration is freer, cough is effective, rest is
possible, and the patient is able to resume even
rather heavy labor in a relatively short time. In
patients with pulmonary emphysema or marginal
respiratory reserve of any cause, the splinting of

124

THE JOURNAL-LANCET

Fig. 1 a (left). Note
severe subcutane-
ous emphysema, b
(right). Final ra-
diologic result.

Fig. 2 a (left). Admission roentgenogram showing multiple rib fractures, fracture of the left clavicle, and left pneu-
mothorax with severe shift of mediastinal structures to the right, b (center). Improved appearance of chest two
days after injury, c (right). Chest roentgenogram twenty-seven days after injury.

Fig. 3a (left). Im-
mediate preopera-
tive film, b (right).
Immediate postde-
cortication film.

APRIL 1958

125

respiration with simple rib fracture may be a
serious handicap and lead to the accumulation of
pulmonary secretions and consequent atelectasis
and pneumonitis. In these patients, application
of certain measures, which will be discussed
under the heading of major thoracic trauma, may
be necessary.

MAJOR THORACIC TRAUMA

Injury to the chest of a more serious nature is
best considered from the viewpoints of: (a) the
effect on the organs and structures under the
protection of the rib cage and (b) the effect on
the mechanics of respiration. In considering the
organs and structures which may suffer damage
in any thoracic injury, we at once recall the
heart, lungs, great vessels, esophagus, trachea,
bronchi, thoracic duct, and diaphragm. There
are, of course, several additional important struc-
tures which depend upon the protection of the
rib cage albeit they lie below the diaphragm.
These are primarily the spleen, liver, pancreas,
and kidneys. Some of the hollow viscera, such
as the stomach, duodenum, and portions of the
colon, are at least partially intrathoracic.

The organ most often presenting clinical evi-
dence of damage in major chest trauma is the
lung. Simple contusion of the lung with a
localized area of parenchymal hemorrhage casts
a shadow upon the x-ray film but usually re-
quires no specific treatment. More often there is
a laceration of the parenchyma with air leak and
bleeding, which cause a hvdropneumothorax on
the upright chest film. While the air leak may
not be rapid, it always has the potential of caus-
ing serious disturbance, such as a tension pneu-
mothorax. The bleeding most frequently is from
the low pressure pulmonary system and tends to
cease spontaneously before any great amount
is lost. Treatment consisting of controlled suc-
tion through an intercostal catheter brings
prompt expansion of the lung and evacuation of
the blood. Early active treatment is important
to avoid the problems presented by tension pneu-
mothorax (figure 2) or clotted hemothorax (fig-
ure 3) and trapping of the lung in a collapsed
state.

Case 2. J. T., a 46-year-old white man was crushed
between the bumper of an automobile and a wall. He
was severely dyspneic and cyanotic on arrival at the
hospital. The admission x-ray film showed multiple
rib fractures, fracture of the left clavicle, and left pneu-
mothorax with severe shift of the mediastinal structures
to the right (figure 2a.) Treatment was begun within
an hour after the injury and consisted of ( 1 ) suction
applied to a catheter inserted in the third interspace in
the midclavicular line, (2) Novocain block of the 12
intercostal nerves on the left, ( 3 ) nasotracheal catheter
suction on 4 occasions during the hospital stay. Im-

proved x-ray film appearance of the chest two days after
injury ( figure 2b ) was correlated with great improve-
ment clinically. Figure 2c shows the condition of the
chest twenty-seven days after injury at which time the
patient was clinically well and doing light work at home.

In this case, the simple measures mentioned
previously brought dramatic improvement and
led to the ultimate attainment of a good clinical
result.

Case 3. M. II. is a 22-year-old man in whom left hemo-
thorax developed as a residt of an injury in August 1952.
Blood was aspirated from the chest occasionally but
never completely. This blood clotted, became organized,
and was gradually converted to mature scar tissue. When
he was seen in March 1953, the severe contraction of
the left hemithorax and trapping of the lung were ob-
vious. Decortication was performed. The entire visceral
and parietal peel were removed. The lung expanded
well to fill the hemithorax. Figure 3a was taken just
prior to operation. Figure 3 h is an immediate postop-
erative film.

The fragile vascular spleen is frequently dam-
aged with chest trauma. Hemorrhage tends to
be continuous and serious when the capsule is
lacerated together with the pulp. If the capsule
remains intact but the pulp is lacerated, delayed
hemorrhage, particularly within the first three
weeks after the injury, is possible. The treatment
is splenectomy.

The liver is similarly liable to fracture and
hemorrhage. In addition, the escape of bile into
the peritoneal cavity may complicate the prob-
lem. In such cases, the treatment is debridement
of devitalized parenchyma, control of bleeding
points, and drainage of the area.

The kidney may suffer contusion or laceration
in a chest injury. Bleeding occurs, however, in
a comparatively closed space and has a greater
tendency, therefore, to be self-limited than is
true in the case of wounds of the liver or
spleen. Emergency treatment consists of suppor-
tive blood transfusion, and early operation is
onlv rarely necessary.

Traumatic pancreatitis is diagnosed by the
elevated serum or urine amylase and is, perhaps,
best treated by nonoperative means as with
acute pancreatitis of undetermined etiologv.

Damage to the heart is common and varies
from transient pericarditis to severe contusion
and even rupture of the myocardium. Damage is
detected and progress followed by serial electro-
cardiograms, as well as repeated physical ex-
aminations. Patients with evidence of myocardial
damage are treated with rest, as one woidd treat
a patient with coronary thrombosis. There would
seem to be, however, little place for the use of
anticoagulants in this circumstance. Cardiac
tamponade may occur early due to active bleed-
ing or two to three weeks later as a small amount

126

THE JOURNAL-LANCET

Fig. 4 a (left). Im-
mediate preopera-
tive portable an-
teroposterior film of
tire chest, b (right).
Portable anteropos-
terior chest film
immediately after
open pericardioto-
my. Catheter in
c o m m u n i c a t i o n
with pericardial
space but not in
contact with the
heart.

of blood in the pericardial sac by hemolysis in-
creases its osmotic pressure and causes a shift
of fluid into the sac in the manner that a sub-
dural hematoma increases its volume. One
should, therefore, be alert for the classic signs
of increased venous pressure, falling arterial
pressure, paradoxical pulse, and increased card-
iac silhouette on the x-ray film. The heart tones
are muffled in a typical case, but this is an un-
reliable sign in our experience. Paracentesis
should be performed for relief of symptoms and
may be lifesaving. Open pericardiotomy through
the bed of the left fifth costal cartilage with
evacuation of the liquid and clotted blood and
postoperative suction drainage is indicated if
tamponade recurs. This procedure appeals to us
as a simple, safe, and somewhat more certain
method of evacuating the pericardial space and
controlling bleeding points.

Case 4. M. D., a 46-year-old man, suffered a steering
wheel injury of the chest and a fracture dislocation of
the head of the right femur in an automobile accident.
He was severely dvspneic, cyanotic, hypotensive, and
mentally clouded when admitted to the Minneapolis

Fig. 5 a (left). Film taken
shortly after injury, b (right).
Film taken two years after
injury. Residual traumatic
aneurysm has been resected
and replaced with an ivalon
prosthesis. (Photograph pre-
sented witli permission of C.
R. Hitchcock, M.D., chief of
surgery, Minneapolis Gen-
eral Hospital).

General Hospital. Adequate ventilation was regained
by correcting left pneumothorax with intercostal cath-
eter drainage, and a tracheotomy was performed. Ap-
proximately two weeks after injury, the patient devel-
oped the classical signs of cardiac tamponade. Figure
4d is an immediate preoperative portable anteroposterior
film of the chest. Figure 4b was taken just after open
pericardiotomy and removal of 700 cc. of old blood.
The catheter has been sutured in place in communica-
tion with the pericardial space but not in contact with
the heart. There was no recurrence, and recovery was
complete.

Of the great vessels, the aorta is the one most
commonly injured. It tends to tear at a point
just distal to the left subclavian artery. The
common explanation for this is said to be that
the aorta is fixed in this area by the ligamentum
arteriosum and upper extremity vessels. It may
be that the narrow, tough, unyielding left vagus
and recurrent laryngeal nerves provide the ful-
crum over which the aorta is fractured. In the
past, we could offer, in addition to supportive
blood transfusion, little more than prayer. How-
ever, laboratory experience with the method
of bypass of the occluded descending thoracic

APRIL 1958

127

aorta pumping oxygenated blood from the left
atrium to the femoral artery recently gave us
courage to operate with near success upon one
case of acute rupture of an aneurysm of the de-
scending thoracic aorta. It seems only logical
that this method will be applied successfully to
traumatic rupture of the thoracic aorta.

Case 5. G.D., a 15-year-old boy, was in an auto-
mobile accident in which he sustained mild head and
kidney injuries and more severe trauma to the chest.
X-ray film evidence of a mass developed in the apex
of the left chest. Physical examination revealed a bruit
in this area, signs of coarctation of the aorta (hyperten-
sion in the arms and hypotension in the legs), and an
acute left ventricular strain pattern on the electrocardio-
gram. These signs gradually subsided over a period of
one month. Figure 5 a was taken shortly after the acci-
dent. Figure 5b was taken two years after injury. The
residual traumatic aneurysm was resected and replaced
with an ivalon prosthesis.

Fracture of the trachea causes an air leak to
the soft tissues, and, if the fracture site is separ-
ated sufficiently to enable the peritracheal soft
tissue to fall in, respiratory obstruction occurs.
Air leak to the mediastinum may cause compres-
sion of the low pressure vena cavae and pulmon-
ary vessels with consequent circulatory failure
due to poor filling of the heart. Immediate
tracheotomy and passage of the tube beyond the
area of tracheal tear may be lifesaving by re-
establishing the airway and decompressing the
mediastinum. Fracture of a major bronchus
causes a pneumothorax and an air leak which
cannot be overcome with intercostal catheters.
Nevertheless, the catheters prevent or relieve a
tension pneumothorax and are essential emer-
gency measures to maintain life until definitive
treatment can be undertaken. After the im-
mediate threat is removed, fracture of the
trachea or a major bronchus is best treated by
early operation and primary repair of the lacer-
ation. This solves the immediate problem of air
leak or respiratory obstruction and prevents the
later complication of tracheal or bronchial sten-
osis.

Aside from the problem of injury to the
various organs housed within the rib cage, we
are concerned with the disturbance in the physi-
ology of respiratory function caused by major
nonpenetrating injuries of the chest.

Normal respiratory function resolves itself into
two parts : ( 1 ) ventilation of the pulmonary
alveolus and (2) gas exchange at the alveolo-
capillary junction. While there may certainly
be disturbance in gas exchange due to parenchy-
mal edema and hemorrhage in areas of contusion
and laceration of the lung, the greatest distur-
bance in respiratory function residts from the
effect of trauma upon the mechanics of ventila-

tion. Therefore, for the puqx>se of this presen-
tation, disturbances at the alveolocapillary inter-
phase will be disregarded.

The normal movement of air in and out of the
lungs depends upon: (1) the integrity and mo-
bility of the thoracic cage and diaphragm, (2)
elasticity and distensibility of the lung, (3) an
intact pleura, and (4) a clear airway.

Each of the foregoing factors must be con-
sidered individually as we approach the prob-
lem of correcting disturbances in ventilation as-
sociated with chest injuries:

1. Integrity of a mobile thoracic cage and dia-
phragm involves: (a) sufficient rigidity of the
chest wall to prevent any paradoxical motion
under physiologic pressures, sufficient volume to
allow adequate exchange, and sufficient mobility
for expansion in all diameters; and (b) a good
mobile capacity of the diaphragm, for, in quiet
breathing, this muscle is said to account for 60
per cent of the total air ventilated.

Clinically, after injury with multiple rib frac-
tures, we often see loss of rigidity and paradoxi-
cal motion of the chest wall on respiration. This
paradoxical motion serves to increase the physio-
logic dead space by shuttling air back and forth
between that portion of the lung subadjacent to
the area of “flail chest” and the remainder of
the lung. Perhaps, of equal importance, paradoxi-
cal respiration acts as a handicap to effective
cough. The canvas rib belt or adhesive strapping
serves to minimize the paradoxical motion. Mea-
sures aimed at stabilizing the chest wall by use
of an external traction apparatus have long been
standard practice. However, it has been our
experience that, if we direct our efforts toward
correcting the other more easily controllable
alterations affecting ventilation, the use of an
external traction apparatus is rarely necessary.
Any advantage of external traction is probablv
outweighed by its disadvantages. One disad-
vantage is that the apparatus and dressing pre-
vent easy access to a portion of the chest for
physical examination and nursing care. Another
and more important disadvantage is that the at-
tachment of an apparatus of any kind to a
patient tends to discourage his being turned
frequentlv, and we lose, as a result, the aid of
gravity in clearing bronchial secretions.

Effective restriction of mobility of the chest
wall is imposed by the involuntary spasm of
muscles in response to pain. In the patient with
severe embarrassment of respiration, opiates are
to be avoided because of their depressant effect
upon the action of the bronchial cilia, the cough
reflex, and the respiratory center. Pain in this
situation is ideally and simply controlled bv

128

THE JOURNAL-LANCET

paravertebral intercostal nerve block depositing
5 to 10 cm. of 1 per cent procaine just inferior to
the angle of each affected rib plus one or two
ribs above and below those affected. It is a
relatively simple bedside procedure to block all
the intercostal nerves on one or both sides. The
relief of pain ends splinting, with the residt that
the depth of respiration is increased and cough
is no longer suppressed. This is a rewarding pro-
cedure in that the clinical improvement is often
dramatic, and even the most undemonstrative
patient cannot conceal his gratitude. In most in-
stances, the Novacain block brings relief which
far outlasts the anesthetic effect and frequently
only a single injection is required.

The diaphragm is the single most important
respiratory muscle. We must take every step to
remove handicaps to its freedom of action. The
aforementioned Novacain intercostal block con-
tributes a good deal by the relief from splinting
of the diaphragm due to pain. Abdominal dis-
tention due to adynamic ileus associated with
the chest injury or reflecting a concomitant ab-
dominal injury may seriously impair diaphrag-
matic motion. Since abdominal distention caused
by ileus is much easier to prevent than to correct
after it is established, the prompt early place-
ment of a nasogastric tube is important in pre-
serving mobility of the diaphragm and, in addi-
tion, is good first aid treatment of possible but
as yet undiagnosed intra-abdominal injury. The
gastric suction should be maintained until active
bowel sounds are present.

2. In normal ventilation, the lung must be
distensible so that the lung volume can increase,
and it must be elastic to permit passive recoil
during expiration. After an injury, the factors
of distensibility and elasticity of the lung are
disturbed in areas of contusion and hemorrhage
into the parenchyma. Such changes are not
easily or rapidly reversible. We will, therefore,
accept this alteration and extend our efforts in
other more profitable directions.

3. An intact pleura is essential for efficient
ventilation of the lung. In a pneumothorax, any
expansive force is partially lost on the elasticity
and distensibility of the air in the pleural space.

A pneumothorax is almost always present in
a serious chest injury and is readily seen on the
upright x-ray film of the chest. The importance
of taking the film in the upright position is
worthy of emphasis. On a flat film, considerable
fluid may be layered out posteriorlv and air
anteriorly with the lung suspended between
these two and with lung markings reaching the
chest wall laterally. Sizable pneumohemotho-
races have been overlooked on the flat film by

c

Fig. 6 a. Simple water seal drainage, (b). Simple water
seal drainage with trap bottle to collect secretions, (c).
Three bottle suction.

even the most experienced physician. If it is
felt unwise to secure an upright film because of
the patient’s precarious condition, the lateral
decubitus film will serve as an excellent second
choice in demonstrating the presence of a pleural
complication. In management, we will be guided
by the general rule that the pleural space must
always be kept empty, and one of the first acts
of treatment should be to place a catheter in
the pleural space and apply suction ( figure 6 ) .
The third interspace in the midclavicular line is
a convenient area to place the largest urethral
catheter that will pass through the available tro-
car. This catheter removes the air readily but is
not always successful in removing the blood.
In the latter circumstance, a second catheter
should be placed in the sixth or seventh inter-
space in the midscapular line.

This procedure is illustrated in figure 6. Simple
water seal drainage is shown in figure 6a. A
column of water equal to the negative intrapleur-
al pressure prevents aspiration through the
catheter to the chest cavitv. For this reason,
the water seal bottle must be well below the
level of the patient ( floor level is usual ) . As
positive intrapleural pressure on exhalation be-
comes sufficient to overcome the column of
water between the tip of the water seal tube and
the surface of the water, air and fluid in the
pleural space are discharged into the water seal
bottle. Since it is desirable to have as little resist-
ance as possible to egress from the pleural space,

APRIL 1958

129

the tube should be no more than 1 cm. below the
surface of the water in a gallon bottle.

Figure 6b illustrates simple water seal drain-
age with a trap bottle to collect secretions and,
thus, prevent change in the fluid level and con-
sequent change in the resistance to outflow
through the water seal.

Three-bottle suction is portrayed in figure 6c.
Trap bottle, water seal, and controlled negative
pressure suction bottle comprise the series. Suc-
tion is applied to the third bottle bv a Stedman-
tvpe pump or the common laboratory water
suction, which is available in all hospitals. The
tube, which is open to the atmosphere, is placed
14 cm. below the surface of the water. Thus, we
know that when the suction apparatus pulls air
from the atmosphere through this tube, we are
maintaining 14 cm. negative pressure throughout
the system. Fluid aspirated from the chest drops
into the trap bottle, and air leak is manifested
by bubbling through the water seal bottle. The
water seal bottle also prevents aspiration to the
pleural space if the suction pump should fail.

In addition to assisting ventilation by allowing
the greatest possible expansion of the lung,
catheter drainage indicates the amount of blood
lost in the chest cavity and also tells if and when
the bleeding or air leak ceases. With the know-
ledge that while the chest catheter is in place,
a tension pneumothorax will not develop and
blood will not silently accumulate in the chest
cavity, the physician is permitted a much less
troubled sleep.

4. The fourth factor in proper ventilation of
the lungs is a clear airway. The maintenance of
a clear airway is normally achieved by ciliary
action, the cough reflex, positional change and
postural drainage, bronchial peristalsis, and col-
lateral respiration. The cilia clear the airway bv
propelling a blanket of mucus along the tracheo-
bronchial tree. Foreign bodies are moved toward
the larynx on this blanket. Ciliary action is im-
paired by drying, by drugs which thicken or thin
the mucus, and bv anesthetics. Thus, we must
keep the patient’s atmosphere humid, avoid
drugs of the nature of atropine or potassium
iodide, which alter the character of the mucus,
and avoid opiates which depress the cilia.

Coughing is essential to the maintenance of
the airway and depends upon the integrity of
the cough reflex along with an ability to build
up an adequate volume and pressure behind
a closed glottis and then release it suddenly.
Relief of pain, stabilizing the chest wall, and
correcting pleural complications all contribute
to a more effective cough. Most important of
all, patients must be informed of the reason for

coughing and raising mucus and then be en-
couraged frequently by the nurse and physician
to do so. In those cases in which the patient
cannot bring himself to cough, suction applied
to a catheter passed through the nose and into
the trachea removes secretions and teaches the
patient that he can indeed cough (figure 7).

A catheter possessing a gentle curve passes
most readily through the larynx. Plastic dispos-
able catheters especially designed for this pur-
pose are available. However, an ordinary ure-
thral catheter serves very well. The catheter
is passed to the posterior nasopharynx and ad-
vanced quickly synchronous with inspiration
until the larynx is passed. Success will be the
reward of persistence. Signs indicating that the
catheter is propexly placed are apparent when:
( 1 ) the patient coughs due to the presence of
the foreign body, (2) he is unable to speak
above a whisper because the tube passes be-
tween the vocal coxxls, and (3) air may move in
and out of the catheter as the patient breathes.

Suction should be maintained for only brief
periods and is stopped by removing the thumb

Fig. la. Catheter entering the esophagus and illustrating
the advantage of an anterior curve in the catheter tip.
(b). Holding the tongue forward occasionally aids in pass-
ing the catheter to the trachea.

130

THE JOURNAL-LANCET

Fig. 8. Tracheotomy showing anatomic dead space re-
duced by about 75 cc.

from the open arm of the Y connector. The cathe-
ter is left in place during these periods of rest. At
each session, the intermittent aspiration should
be continued until there is no further return. If
the direction of the catheter's curve is known,
it can be passed into either main bronchus.

The effect of gravity on drainage of bronchial
secretion is well known and accounts for our
rather routine order to turn patients frequently.

A very important mechanism in maintaining
a clear airway is collateral respiration, which
allows air from a well-ventilated lobule of lung
to pass into an adjacent lobule whose bronchus
may be plugged. With the accumulation of air
peripheral to the block, the cough again becomes
effective in clearing the mucus. In cases in which
mucus or blood blocks a bronchus and causes
atelectasis of an entire lobe or lung, collateral
respiration cannot play a part in relieving the ob-
struction. In this circumstance, the body must
rely upon the action of the cilia and the pull of
gravity to dislodge the blocking agent. These
two mechanisms are often ineffectual and always
slow enough so that aspiration of the obstruct-
ing mucus is essential. This may often be ac-
complished by nasotracheal suction (figure 7),
and this bedside maneuver should be tried as
soon as the diagnosis is made. If this method
fails to accomplish re-expansion of the atelectatic
lung, bronchoscopy would ordinarily be con-
sidered as the next step. If bronchoscopy is not

available, however, or if repeated bronchosco-
pies are necessary, a tracheotomy should be
provided in order to clear the tracheobronchial
tree of mucus by suction as often as necessary.

From several viewpoints, a tracheotomy is an
extremely useful procedure in patients with chest
injuries. It has some disadvantages, but these
are outweighed in importance by its advantages
(figure 8).

Advantages:

1. Anatomic dead space is reduced by approxi-
mately 75 cc.

2. Resistance to air flow through the naso-
oropharynx and larynx is avoided with the result
that: (a) tendency to paradoxical motion of the
chest wall is minimized and ( b ) air leak from the
lung may be decreased.

3. Tracheal secretions may be aspirated as fre-
quently as necessary by the nurse.

Disadvantages:

1. Effective cough is lost and the patient must
rely upon his attendants to keep his airway clear.

2. The warming and humidifying action of
the nasal passage is lost, so that secretions tend
to dry and water loss may be excessive.

Indications for tracheotomy should be liberal,
but we must recognize that as we perform the
tracheotomy we assume certain obligations to
the patient. Among these are removal of tracheo-
bronchial secretions, prevention of excessive dry-
ing of the respiratory tract, and replacement of
fluid lost by virture of the tracheotomy.

SUMMARY

When a patient with an acute chest injury is
seen in the emergency room, an attempt should
be made to maintain circulation by replacing
blood loss as may be indicated by signs of shock
and controlling obvious points of hemorrhage.
Simultaneously, the factors concerned with the
mechanics of ventilation are considered. Of the
various measures discussed, placement of the
intercostal catheter, tracheotomy, and intercostal
nerve block are the procedures most often em-
ployed as lifesaving measures in the emergency
room. Frequently, these are the only measures
necessary to a good result. Laceration of the
liver or spleen is so commonly a part of any chest
injury that we must be extremely sensitive to
signs of intra-abdominal bleeding or evidence of
blood loss beyond that which is estimated from
the chest x-ray film or suction trap bottle to have
been lost into the chest. If there is even the
slightest question of intra-abdominal bleeding,
the patient’s cause is best served by exploratory
laparotomy through an upper abdominal mid-
line incision.

APRIL 1958

131

The Tuberculin Test

PAUL S. DODD, D.V.M.
Danville, Illinois

Forty years ago, a member of the Bureau of
Animal Industry made the following state-
ments to a veterinary college class: “We are
going to tuberculin test all the cattle in the
United States. We are going to eradicate bovine
tuberculosis." To envision the fulfillment of such
a stupendous undertaking at that time was be-
yond our comprehension. Yet, in one decade,
practically all the cattle had been tested at least
once. In two decades, 95 per cent of the counties
were accredited. In other words, we had re-
duced the incidence of reactors to less than 1/2
of 1 per cent.

Over 176 million tests had been made, and
more than 3 million reactors had been found and
slaughtered. In forty years, the disease has been
practically eradicated or, at least, reduced to the
minimum. For the fiscal year of 1956, over 9
million cattle were tested, with an incidence of
infection of only .15 of 1 per cent. In 1917, the
incidence of infection was 3.2, increasing to 4.9 in
the early twenties and gradually decreasing in
the succeeding years.

My personal experience as a student assistant
in tuberculin testing had been confined to the
old time consuming subcutaneous method where-
by 1 veterinarian could test only 40 to 50 head
of cattle in twenty-four hours. Therefore, the
goal outlined in the statement quoted seemed
somewhat exaggerated to me. But, the speaker
had predicted that a new, more reliable, and
much faster test would be available. He was, of
course, referring to the intradermal test which
had survived a period of experimental checks
and, since 1920, has been a widely accepted
method.

Every disease control program must have
many good reasons for its existence, and this one
was certainly no exception. Tuberculosis of the
food producing animals was at one time the most
serious disease with which the American farmers
were confronted. The meatpacking industry was
forced to condemn and destroy about 10 per cent
of their swine and beef carcasses because of
tuberculosis. Consequently, they either had to

paul s. dodd is Vermilion County veterinarian and
president of the Illinois Tuberculosis Association.

buy livestock at a cheaper price or subject it to
inspection. An economic problem existed affect-
ing both buyer and producer.

Cattle breeders and dairymen were becoming
more aware of the various dangers of the disease
and the benefits of disease-free animals both
from the beef and milk production standpoint.
Medical men and public health authorites were
cognizant of the fact that milk from infected
cattle was causing appreciable human infection
and loss of life, especially in infants and children.
Forty years ago, it was estimated that 11 per cent
of all infant tuberculosis was of bovine origin.

Realization of these facts resulted in the organ-
ization of the cooperative campaign for the con-
trol and eventual eradication of the disease. Led
by the Bureau of Animal Industry and joined by
the several state livestock sanitary officials,
groups of livestock breeders, and others inter-
ested in the livestock industry, a plan of opera-
tion was developed.

In order to facilitate the testing, definite plans
worked out by the Bureau had to be accepted.
The first involved choice of a uniform type of
tuberculin and a standard dosage. The second
concerned the matter of an indemnity to be paid
by the federal government for infected cattle
and to be matched by the cooperating state, as
well as other incidental expenses and activities
to be carried out by mutual agreement with
counties and other governmental agencies. The
meat packers added their support to the pro-
gram by offering a premium of $.10 per hundred-
weight on swine originating in an accredited
county.

Preliminary testing had been confined largely
to purebred herds on an individual herd basis
with the idea of reaching accredited status. How-
ever, in a very short time, serious consideration
was given to broadening this plan to a definite
region known as the area plan. The county was
used as a unit or area of operation, and counties
were encouraged to employ a county veterinar-
ian. All counties in all states did not adopt this
idea. However, the work was done by federal or
state-employed veterinarians who were assigned
temporarily to a county where men were not
regularly employed. To me, the area plan has

132

THE JOURNAL-LANCET

been a very significant and vital point in the
gradual eradication of bovine tuberculosis. With
this program, it has been possible to test all the
cattle in every county. The idea of having a local
man available and reponsible for the work in his
area was important. For operational purposes, we
divided the counties by townships and tested
each as a unit. We started in one corner of a
township and stopped at every farm on every
road until every herd in the township was tested.
This plan was followed until the county was
thoroughly canvassed. We generally employed a
local helper, a person acquainted in the area, who
not onlv assisted in handling the cattle for test-
ing but notified the cattle owner on the previous
day that we woidd be there and that he should
have his animals properly confined. I would like
to state that while these plans worked, they were
not always as simple as they may sound. In the
first place, a small percentage of owners were
not at all cooperative, and a considerable amount
of time was required to convince the farmers of
the efficiency of the program. In some instances,
a sheriff and his deputies were necessary to com-
plete the testing of recalcitrant owner’s cattle.
It was very discouraging to be met at the farm
entrance by a belligerent owner with defiance in
his eye and a shotgun in his hand. At that time,
many farms were not well equipped to handle
the cattle; barns and fences were often inade-
quate; and temporary facilities were often too
temporary.

The cattle in many instances were none too
cooperative either! Weather conditions could
often ruin the best laid plans. Roads in the early
days were quite often impassable. If conditions

I prevented working on planned injection dates,
the work could be postponed, but it was con-
sidered a cardinal sin not to make the readings
after the cattle had been injected. We walked
many miles through rain, mud, and snow to com-
plete the job. Sanitary surroundings on many
farms were far from admirable, and, in the case
of infected premises, we were often obliged to
enforce cleaning and disinfecting practices by
withholding indemnity payments until the job
was completed. A minor problem in some
localities, especially in small towns and suburban
areas, was the one-cow herd. They were hard
to find, but the local lay helper proved his value
in such situations. This factor was and continues
to be important, as the family cow was quite
often infected. We were as diligent in locating
and testing the single animal as the large herds.
To err is human, and we, no doubt, made many
mistakes. We have probablv condemned some
noninfected cattle, and we may have passed

some reactors. However, the ultimate results
seem to indicate that a highly satisfactory level
of performance was acquired and maintained.

Regularly employed veterinarians soon became
very efficient in making injections and readings.
Herd histories and physical conditions as well
as keen observation of sanitary surroundings,
food, and water supplies were significant. Post-
mortem reports on reactors helped the operator
judge future readings. Years ago, when the dis-
ease was more prevalent, we considered 10 per
cent of cases with no visible lesions a good
record. However, as the infection decreased, the
percentage of cases without visible lesions in-
creased. While this fact might cause the most
experienced operator some embarrassment, it is
not unusual, and we bave continued to use our
judgment and remove the animal from the herd.
In more recent years, we have become more
tolerant and do, on occasion, hold an animal in
isolation for retests before making a final de-
cision. Some generalized cases did not react to
tuberculin but were often removed from the
herd because of clinical symptoms observed by
the veterinarian. This was especially true in
herds with persistent infection where obscure
but certain infeetors were in evidence.

When an infected herd was found and reactors
removed, the herd was subjected to 2 sixtv-day
retests at least, more if infection persisted. In
many cases, 6 to 12 retests were necessary to
find and remove the last victim. These herds
were then generally placed on an annual test
basis until all possibility of further trouble was
eliminated. By doing this on each area retest, a
thorough follow-up was accomplished.

The 2 tests formerly used were the subcutane-
ous and the ophthalmic. The subcutaneous was
a thermal test. After 3 preinjection temperature
readings on each animal at two-hour intervals, a
quantity of tuberculin was injected subcutane-
ously. Beginning eight hours after the injection,
temperature readings were resumed at two-hour
intervals and recorded on a chart, together with
the preinjection readings and proper identifica-
tion of each animal. Five postinjection tempera-
tures were recorded. Reactions were indicated
by characteristic elevations in temperature ( rain-
bow-shaped on the chart) beginning at the
eighth hour and increasing 3 to 5° at about the
twelfth to fourteenth hour and then gradually
receding. No variation between the pre-and
postinjection temperatures constituted a negative
reaction or absence of infection.

The ophthalmic test was used to some extent
years ago, both in conjunction with the subcu-
taneous and the intradermal and also alone. It

APRIL 1958

133

was never considered very efficient and, because
of its many bad features, was finally discon-
tinued. The intradermic test is made by injecting
one minim of specially prepared tuberculin be-
tween the layers of skin of the caudal fold. Re-
actions are indicated by a noticeable swelling
at the injection site. These swellings may be
small as a pea, hard and circumscribed, or as
large as a hen egg. They may be soft and doughy
and diffused, with a feeling of unusual warmth,
but with no particular line of demarcation.

Routine testing can and does become rather
tiresome and boring. Were it not for the sincere
dedication to the ideal of eradication uppermost
in the minds of experienced operators, the pro-
gram would not have been so successful. How-
ever, complacency has no part in any disease-
control program. Just when we seem to have
sunk into an indifferent routine, we discover a
new and exciting case and with it a new surge
of enthusiasm for the work as well.

As the disease has diminished, the period of
accreditation has been extended. At present,
when the disease rate is less than 1/10 of 1 per
cent, the period for a complete retest is six years.
In some areas, even on some farms, that could
be too long. We try to keep closer observation
on those areas, but our greatest fear is that some-
where, sometimes an unusually virulent infector
may appear to destroy many animals and years
of hard work. Thus, we must forever be on the
alert.

Some of the complications encountered in our
program were due to infection from other than
bovine sources. Swine and avian infectors were
quite common in some areas, doubtless causing
false reactions on occasion, yet, such pronounced
reactions that the operator had to condemn the
animal.

Avian infection was found to be quite ex-
tensive in some areas of Illinois, and swine in-
fection was correspondingly high. There is no
known type of swine tuberculosis, so that species
was either infected by the avian, bovine, or
human type. In 1928, in a survey testing pro-
gram in one central Illinois county, 22 per cent of
the poultry over 1 year of age reacted to the
intradermal test. In another survey made on
poultry and swine on the same premises in one
county, swine infection was found to exist on
only one farm where poultry infection was not
found, and, in this particular instance, the swine
were new additions.

Field experience indicates that avian infection
can be contracted from the human being as well.
Gross lesions have been found in poultry on
premises harboring known cases of human tuber-

culosis. While not proved, it would seem poss-
ible that a chain of infectors from the human
being through the avian and swine to the bovine
and thence back to the human being can exist.

European studies have revealed that the bo-
vine type is sometimes responsible for open pul-
monary tuberculosis in man, and that man can,
in turn, spread the infection to the cows he
milks and cares for. However, if the type of in-
fection in man is of human origin, the danger to
the bovine is meager.

A report from Sweden blames a woman worker
on a large dairy farm as the infector of 47 head
of cows. This woman was suffering from pul-
monary tuberculosis, and the disease in the cattle
developed some ninety days after she was im-
ployed. In this instance, detailed laboratory tests
proved conclusively that the infection was of
human origin.

Just this last year, a dairy herd in one of our
Illinois counties suddenly disclosed several re-
actors.-On following through, it was found that
the herd owner had an active case of tubercu-
losis, and he was immediately hospitalized. Typ-
ing was inconclusive at last report.

One result of this incident was the adoption
of a resolution bv the Executive Committee
of the Illinois Tuberculosis Association, which
recommended that it should be mandatory for
all persons in contact with tuberculin positive
cattle to be tuberculin tested themselves, and, if
their reaction were positive, they should have
chest x-ray films taken and any other diagnostic
tests necessary to determine the presence of
active tuberculosis.

Our health and agriculture departments have
been notified of this action and have agreed to
cooperate in fulfilling the recommendation. Per-
haps some valuable and interesting information
may result.

We have encountered several instances in
which swine were responsible for a bovine out-
break. Probably one of the most interesting
cases of swine as bovine infectors was demon-
strated in LaSalle County, Illinois, a few years
ago. In a herd of 35 head of Guernsey cattle
which had shown no infection since 1941, 17 1
reactors appeared on the annual test; 16 head
showed lesions of tuberculosis on the post-
mortem report; and 6 head were condemned as
generalized cases. These cattle were all young,
between 2 and 10 months of age. On the first
sixty-day retest, 6 more reactors were found; 2
of them were condemned. All 6 were under 10
months of age. When the first reactors were
found, everyone concerned was quite interested
in finding the source of this unusual occurrence,

134

THE JOURNAL-LANCET

and, after some investigation, the swine herd was
regarded with suspicion. All breeding swine
were subjected to the intradermal test with bo-
vine tuberculin, and more than 40 of the 80 head
reacted. The entire swine herd was sold for
slaughter, and all subsequent retests on the re-
maining cattle have been negative. It was learned
that these young cattle had been confined with
the swine herd during the spring and early
summer. The adult cattle on the farm had never
been in contact with the swine herd or with
the young cattle which reacted.

Just a few years ago, we discovered 2 reactors
in a cattle herd of 4. There had been no pre-
vious infection on the farm. We held the animals
for retest, and they reacted again. They were
sent to slaughter but showed no macroscopic
evidence of tuberculosis. We tested the poultry
and the brood of 4 sows on the farm. Three of
the sows reacted; 1 was negative. Investigation
revealed that the 3 sows had been purchased
the previous year at a sale some distance away.
The poultry were negative.

Swine and avian exposure no doubt cause
some of the atypical reactions and account for a
percentage of the cases without visible lesions.
Yet, some are so impressive that they demand
radical action. Veterinary philosophy inclines to-
ward the preventive phase of disease control.
We would much rather remove a suspicious
animal from the herd than take a chance on leav-
ing future potential infectors.

Our friend, Dr. J. A. Myers, once said: “In
human tuberculosis, many problems which are
today considered controversial have already been
solved by the veterinary profession.”

I am not sure of all the specific problems to
which the doctor refers, but the fact that we
test all the cattle, remove them from the prem-
ises, and conduct a thorough follow-up are most
important.

These points pose an example for all workers
in the tuberculosis field whether veterinary,
medical, public health, nursing, or volunteer.
Our task may appear comparably simple and
easy, but I can assure you it never has been or
ever will be.

In the first place, organization with dedicated
leaders was necessary and an extensive educa-
tional program as well. Uniform methods of
operation with a standardized tuberculin in the
hands of trained personnel who were deter-
mined to accomplish the job at hand were of
prime importance.

As an active member of our countv and state
tuberculosis associations for several years, I have
had ample opportunity to observe the aims, am-

bitions, and problems of the professional and
voluntary workers. As is the case in any organi-
zation, there exists an honest difference of opin-
ion regarding the best methods necessary to
achieve the goal— the eradication of tuberculosis.

Perhaps my viewpoint concerning the efficien-
cy of tuberculin testing is somewhat different
from that of a medical man, but it would appear
that we could learn from one another. We know
what causes the disease, but we have no accept-
able preventive to date. Medical and surgical
treatment have reached a new high in efficiency,
reducing hospital confinement appreciably. I
will not quote statistics; they are available to
all. It appears then that the discovery of un-
known cases is the most difficult problem for
both doctor and veterinarian. Unless we use all
the tools at our command, we are not taking ad-
vantage of our opportunities, and, certainly, one
of the simplest tools is that of the tuberculin
test. I have noticed in recent years the increased
interest shown by various persons in the value
of the test and a more concerted effort on their
part to stimulate others to use it more carefully
as a case-finding tool. I have tried to listen ob-
jectively to all the arguments pro and con, but
I am convinced that if this tool were used wisely
and diligently, we would reap a harvest of pre-
viously undetected cases. Certainly, the results
of the bovine campaign have proved this point,
and I can think of no obstacles more formidable
than those the veterinarian has conquered.

I believe the medical profession and other
agencies should agree on a type of tuberculin
and standard methods of administration and ob-
servation. The Bureau did this for us and avoided
much confusion. I believe the general practi-
tioner lacks interest or is indifferent to the dis-
ease and the part they can and should take in
the eradication program. I have had physicians
tell me that we have had and always will have
tuberculosis. I’m quite sure that these pessimistic
physicians are very much in the minority, but,
since this is a medical problem, it will never be
conquered without the wholehearted support
of that profession.

Someone once said that to permit the death
of people from a preventable disease is a crime
against humanity. I don’t presume tuberculosis
to be a wholly preventable disease at this time,
but, certainly, early case finding will prevent
thousands of deaths, untold suffering, and save
millions of dollars.

It seems that a united effort between our pro-
fessional and voluntary groups could develop a
concerted program of case finding through the
use of the tuberculin test. Surely, a majority of

APRIL 1958

135

medical men would be interested in this eradica-
tion program if they were properly indoctrinated
from a reliable source. If we are to succeed in
our campaign, our educational endeavors must
start at the top with the medical profession. The
family physician must play a key role, lie, of
all people, wields the most influence with his
patients on medical problems. Without his in-
terest and advice no disease-control program can
succeed. It appears to me that the first job of
our voluntary associations is to enlist the cooper-
ation of every physician, acquaint him with the
problem at hand, and encourage him in any way
possible to use the tuberculin test in his private
practice as a diagnostic agent and make plans
for area testing programs where feasible. In
areas with organized medical societies, they
should take the lead in perfecting some type of
working group dedicated to finding every case
of tuberculosis in their respective areas.

This undertaking may appear to be an imposs-
ibility, a too comprehensive plan, and yet, in the
process of total eradication of tuberculosis, it
may become necessary to do more than we need
to do. One sure way of failing to eradicate this
disease is to do less than is required. I am not
unmindful of the other case-finding methods
available, and I most certainly encourage their
unlimited use. However, in view of the recent
adverse criticism of radiation from x-ray (war-
ranted or not), it seems a most appropriate time
to use the most basic of all methods— the skin
test.

Sometimes we cannot see the forest for the
trees seems a classic example of the truth and
reminds me of the story of the boy and the
puzzle. A father gave his small son a jig-saw
puzzle of a map of the world, thinking the task
of putting it together would keep him busy for
a long time. The father was surprised to find that
the boy did the job in a comparatively short
time and asked him how he did it. The boy re-
plied: “It was easy, there is a picture of a man
on the other side, I just put the man together and
the world turned out all right.”

Recently, a local pediatrician related an in-
teresting story. A 3-year-old girl developed some
enlarged lymph nodes in the cervical area. They
were not sensitive but noticeably enlarged and
rather hard. After several weeks of medical and
antibiotic treatment, no improvement was vis-
ible. On an intuition, the doctor used the skin
test for tuberculosis and got a positive reaction.
The nodes were surgically removed, and biopsv
proved them to be tuberculous. This is just an-
other example of finding the unknown case by
using the intradermal test as a routine diagnostic

procedure. A complete follow-up of contacts
has not been made at this time, but it is quite
enlightening to discover what results the small
red spot on a child’s arm may eventually pro-
duce.

I believe physicians and nurses have done
quite a lot of area testing in Minnesota with in-
teresting and profitable results. A group of St.
Louis physicians have also carried on a tuber-
culin testing program in St. Louis County, Mis-
souri, with most gratifying results. Several Illi-
nois counties are extending their school testing
projects. In our city, the annual school health
surveys, which formerly included the tuberculin
testing of the first, fifth, and ninth graders, was
extended to include the high school seniors.
Several formerly unknown contacts were dis-
covered, and one active case in a senior was
disclosed. The additional cost was negligible in
comparison to the results obtained. School sur-
veys, as such, may not appear too productive,
but they certainly make it possible to identify
the areas in which follow-up work should be
done. A map of our city was so pin pointed by
our sanatorium director, as a result of the school
survey, that it shows most clearly and graphically
where the disease is most prevalent. Plans are
being formulated to conduct a thorough case-
finding program in this specified area. If this
proves productive, other areas may likewise be
canvassed.

Another phase of the use of the skin test
which has received verv little attention is the
cost. From what I can learn, more active tuber-
culosis can be found much less expensively, es-
pecially in selected areas, by using this simple
test. In some cases, mass x-ray film surveys
exact a terrific cost with minimum results. I
am yet to be convinced that a skin-test program
in these same areas would not yield better results
at less cost. I believe it should be tried and
followed to the extreme potential.

Since tuberculosis is a very insidious disease,
there is, no doubt, more complacency regarding
its eradication. If it were half as spectacular as
poliomyelitis, it may well have been much nearer
eradication at this time. It seems rather ironic
to me that we have done so much more toward
eradicating tuberculosis from our bovine popu-
lation than from human beings.

Mrs. Edith Backs, executive director of Wash-
ington County, Illinois, had a most interesting
article in the January 1957 issue of Evcn/bodi/s
Health, entitled “Putting the Tuberculin Test
to Work.” I woidd like to quote her 13 reasons
for using the test.

1. When tuberculosis strikes infants, it is often

136

THE JOURNAL-LANCET

quickly fatal. That is why parents and baby
sitters should be tested.

2. Tuberculosis contracted during childhood
may “go to work” during adolescence. That is
why high school students should be tested.

3. Tuberculosis is the chief killer in the 15-
year-age level. That is why everyone in this
group should be tested.

4. Tuberculosis often disables for years. That
is why middle-aged persons with family responsi-
bilities should be tuberculin tested.

5. Tuberculosis may remain inactive for years
only to go on the warpath during old age. That is
why old people should be tuberculin tested.

6. Tuberculosis is especially troublesome when
teamed with diabetes. That is why diabetic per-
sons should be tuberculin tested.

7. Tuberculosis is very prevalent in many for-
eign countries. That is why returning military
personnel should be tested.

8. Tuberculosis is contagious and communi-
cable. That is why all contacts of a known case
should be tuberculin tested.

9. Tuberculosis germs are not revealed by
roentgenogram before they have done damage.
That is why even those who have negative chest
films should be tuberculin tested.

10. When someone in a household has become
infected, others in it may have picked up the
germs from the same source. That is why all in
the home should be tested if one reacts.

11. Tuberculosis can do serious damage with-
out causing symptoms. That is why those in
apparently perfect health shoidd be tuberculin
tested.

12. Tuberculosis can strike anyone. That is
why you should be tuberculin tested.

13. It is tme that many who harbor tubercu-
losis germs will never have trouble from them.
It is also true that no one harboring them is
ever safe. That is why every reactor should have
an annual chest x-ray film taken till he is 99/2
years old.

Yes, x-ray films will detect tuberculosis early,
but the skin test will find it much earlier and at
less cost.

The World Health Organization will hold its eleventh annual assembly
meeting in Minneapolis from May 26 through June 14. This is the first time
the group has ever met in the United States.

In honor of the occasion, The Journal-Lancet is proud to announce that
its June issue will be devoted to the accomplishments, objectives, problems,
and needs of the World Health Organization. Articles on public health written
bv outstanding world health authorities will be presented.

Copies of the Special Issue will be distributed to representatives and dele-
gates of WHO. These may be the only copies of an American medical journal
to be found in doctors’ offices, clinics, and hospitals in the far corners of the
world.

APRIL 1958

137

Tuberculosis from Man to Animals

GEORGE D. MORSE, M.D.
Peoria, Illinois

In the united states, the tuberculin testing of
cattle and the universal pasteurization of milk
have all but eliminated the danger of transmit-
ting tuberculosis from animals to man. The re-
verse, however, is not true. Man’s inability to
adequately subdue the disease in his own species
—although he is certainly equipped with enough
knowledge to accomplish this job— means that
susceptible animals live in constant danger of
catching tuberculosis. This article then will con-
sider principally the transmission of tuberculosis
from man to animals. This is not a minor prob-
lem either from the public health or economic
standpoint. Animals who contract tuberculosis
from man can later pass it on to other animals
and, thence, back to humans, thus acting as re-
servoirs of infection. Financial loss can be of
considerable concern. Ask a dairy farmer who
loses his whole herd without adequate compen-
sation; or, ask a zoo keeper who loses an entire
monkey colony.

Three types of tubercle bacilli must be consid-
ered: the human, bovine, and avian. Avian tuber-
culosis is quite common and is a serious disease
in many species of animals and birds. Only a
very few human cases have been reported in the
literature, and most of these have not been
proved. If avian tuberculosis exists in man, it is
extremely rare, and transmission of avian bacilli
from man to animals probably never takes place.
Differentiation between the 3 types of tubercle
bacilli existing in the warm-blooded animals is
based partly upon cultural characteristics but
mostly on the virulence test. The animals used
in the virulence tests are the guinea pig, rabbit,
and chicken. Frequently, the results of these
tests are inconclusive ( table 1 ) .

The most common domestic animals which
can be infected with tuberculosis are the cow,
pig, dog, cat, horse, and chicken. Each of these
will be discussed briefly. Either from reports in
the literature or from personal knowledge of the
author, the following is a partial list of additional
animals in which tuberculosis has been known to

george d. morse is medical director and superin-
tendent of the Peoria Municipal Tuberculosis Sana-
torium, Peoria, Illinois.

exist: guinea pig, rabbit, duck, goose, turkey,
peacock, pheasant, canary, parakeet, parrot,
guinea fowl, crow, goat, lamb, deer, fox, kanga-
roo, buffalo, mink, elephant, giraffe, striped
gopher, rat, mouse, badger, gnu, antelope, wild
boar, waterbuck, sparrow, squirrel, vole, baboon,
lemur, orangutang, chimpanzee and monkeys of
all varieties. Five groups will be discussed: wild
animals, domestic animals, pets, laboratory ani-
mals, and animals in the zoo.

WILD ANIMALS

Several statements in the earlier literature that
tuberculosis does not exist in wild animals in
their natural state are not true. Tuberculosis
has been reported in many species of wild
animals. The sparsity of these reports can easilv
be attributed to the fact that a wild animal with
tuberculosis is apt to become sick and incom-
pacitated rapidly. It is more likely that it would
succumb to some natural enemy before falling
into a pathologist’s hands. Incidence of the dis-
ease in wild animals would no doubt depend on
how closely they were associated to man.

DOMESTIC ANIMALS

Cow. Much has been written about tuberculosis
in cattle. The cow is susceptible both to the
bovine and human type, but practically all cases
occurring in cattle are due to the bovine bacilli.
Pathologically speaking, the lung is the principal
site of infection, although the liver, spleen, kid-
ney, mucous membranes, udder, and mammary
glands are frequently involved. The most com-
mon mode of transmission from cow to cow is
thought to be by droplet infection through
coughing or expired air. Bovine tuberculosis can

TABLE 1
VIRULENCE test

Tt/pe bacillus

Guinea pig

Animal

Rabbit

Chicken

Human

+

?

O

Bovine

+

+

O

Avian

?

+

+

+ = susceptible
? = slightly susceptible
O = resistant

138

THE JOURNAL-LANCET

be transferred from the cow to dairy workers,
and, in turn, they can transmit it hack to unin-
fected cattle. Even new herds can be infected
in this manner, resulting in serious losses. The
cow is susceptible to human tuberculosis but to
a much lesser extent. With few exceptions, it
is apparent that human tuberculosis in cattle is
a rather benign disease. It is doubtful whether
a cow suffering from human tuberculosis would
be infectious to other cattle or man either
through the milk or through close contact. But,
the tuberculin test would be positive, and, since
it is impossible to tell which type of tuberculosis
exists, the cow must of necessity be destroyed.
Personal communication from a former superin-
tendent of a midwest sanatorium revealed an in-
stance in which the garbage incinerator access-
ible to the sanatorium’s dairy herd was thought
to be the cause of many positive tuberculin re-
actions, and, when the situation was remedied by
fencing, no more trouble of this kind was en-
countered. Recently, a patient was admitted to
the Peoria Municipal Tuberculosis Sanitarium
with minimal active pulmonary tuberculosis. His
disease was discovered through a chest x-ray
film taken because he was the tenant supervisor
of a dairy herd which suddenly had developed
an epidemic of tuberculosis. Unfortunately, it
was never established whether he or the cattle
had human or bovine tuberculous infection.
However, it was assumed that it was bovine be-
cause of the extensive pathology found by the
meat inspectors in the cattle that were destroyed.
Bovine tuberculosis can be missed in a routine
sanatorium examination because the bovine ba-
cilli grow very poorly on the glycerinated cul-
ture media, which is almost universally used, and
in which the human bacilli thrive quite well. It
is suggested that guinea pigs should be used
along with the cultures, since the guinea pig
will be infected equally by both types. When-
ever cultures of a patient’s sputum are persis-
tently negative, but guinea pig inoculations are
positive, the bovine type of bacilli should be
suspected. All dairy workers should have pre-
employment x-ray films taken at regular inter-
vals during employment. Whenever a tuber-
culosis epidemic occurs in a previously unin-
fected herd of cattle, all human contacts should
be immediately x-rayed not only to see if they
are the source of infection but also to see
whether they may have contracted the disease
from the infected cattle.

Pig. Swine are susceptible to all 3 types of
tubercle bacilli. Tuberculosis in pigs is quite
common, but the majority of cases are caused
by the avian bacilli, which is due to the close

association of the swine in barnyards with chick-
ens and other poultry. Eating untreated garbage,
which frequently contains chicken entrails, is
another source. Bovine tuberculosis in swine has
become quite rare because of the corresponding
rarity of cattle tuberculosis. Human tuberculosis
does occur and is caused by eating human gar-
bage. Transmission of tuberculosis from man to
swine by personal droplet infection certainly
occurs infrequently.

Dog. Tuberculosis in the dog is much more
common than usually thought. Because of his
close contact with man, human tuberculosis is
far the most common type of disease, although
he is also susceptible to bovine tuberculosis but
rather resistant to avian. The disease in the dog
is apparently of a mild nature with few symp-
toms, but pathologic reports of autopsy material
leave no doubt that the dog with tuberculosis
should be considered a dangerous pet. The fact
that dogs have not been proved to have trans-
mitted tuberculosis infection to humans is prob-
ably due to the fact that few people have ever
realized that this is a possibility. Tuberculosis
workers should consider all household pets
whenever contact examinations are carried out.

Cat. Tuberculosis in cats is not common. Most
reports of the incidence of the disease in cats
have come from outside the United States, and,
whenever investigated, the vast majority of cases
were bovine. Experimentally, it has been shown
that cats are rather resistant to the human strain
but quite susceptible to bovine tubercle bacilli.

Horse. Tuberculosis in horses is quite rare,
and, when it occurs, it is almost always caused
by bovine bacilli. This rarity is not only ac-
counted for by the decrease in cattle tubercu-
losis, but the incidence in horses was quite low
even when tuberculosis in cattle was prevalent.

Chicken. All types of poultry are susceptible
to avian tuberculosis but are totallv resistant to
the human and bovine type. Chickens apparently
are the most susceptible, while turkeys, ducks,
and geese are less apt to have tuberculosis. The
human being plays no part in infecting the poul-
try by direct contact, but his inability to create
preventive measures can certainly be considered
an undesirable contribution, and any shortcom-
ings in this matter can frequently result in finan-
cial loss to man, not only because of sick chick-
ens but because of transmission of avian disease
to swine and other susceptible animals.

LABORATORY ANIMALS

There are several reports in the literature of
tuberculosis in laboratory animals, most of these
in monkeys. Before the use of isoniazid, tuber-

APRIL 1958

139

Fig. 1. Zoo director holding chimpanzee pre-
liminary to taking x-ray. X-ray cassette is under
director’s shirt.

Fig. 2. Roentgenogram of female gibbon ape.
Autopsy showed acute advanced pulmonary
tuberculosis.

culosis in laboratory monkeys almost always
meant the loss of the entire colony. Cough is
a predominant symptom in the monkey infected
with tuberculosis, and, consequently, through
droplet infection or dust inhalation, monkeys
in near or even distant cages become infected.
Spontaneous tuberculosis also occurs in guinea
pigs. Transmission of the disease from an in-
fected guinea pig to an uninfected pig in a
different cage is quite rare, probably because of
the absence of droplet infection. In the earlier
days when sanatoria made much use of the labor
of convalescent and former patients, occasional
cases of tuberculosis occurred in guinea pigs
which had contracted the disease from caretakers.

PETS

Many animals classified as pets can get tuber-
culosis from their human associates. Undoubted-
ly, tuberculosis in the pet monkey is one of the
principal causes of illness and death. A monkey
can catch tuberculosis very easily, becomes quite
sick, and always dies if untreated. Thus, a posi-
tive tuberculin test in an untreated monkey
means active tuberculosis. It has been shown
that certain birds are susceptible to other than
avian types of tuberculosis. Parrots and para-
keets have been known to be infected with both
human and bovine tuberculosis. If a veterinarian
suspects tuberculosis in anv pet, all human con-

tacts should be x-rayed. It is unwise for persons
with known positive sputa to own pets.

ZOOLOGICAL ANIMALS

Many animals in the zoo can be infected with
both human and bovine types of tuberculosis,
but the monkey is the principal victim. Very
few reports are found of the outbreak of tubercu-
losis in zoos, possibly because they have been
unrecognized or the zoo did not want the public-
ity. However, there is no doubt that it is a very
serious problem (figures 1 and 2).

Animals in the zoo that are most susceptible
are all varieties of monkeys, the hooved animals,
such as the elephants, giraffes, and camels and
the rodents. The cat family appears to be strong-
ly resistant. The following is an account of a
tuberculosis epidemic occurring in the Glen Oak
Park Zoo in Peoria, Illinois. Early in 1956, a
Dinah monkey became ill with respiratory in-
fection and died. An autopsy performed by the
zoo veterinarian and later confirmed by the
pathological laboratory at St. Francis Hospital,
Peoria, revealed far advanced pulmonary tub-
erculosis. In the next few months, tuberculosis
developed in 12 other monkeys. Ten either died
or were destroyed. The entire monkey colony
was tuberculin tested with 1 to 1,000 dilution of
old tuberculin, which is the dose recommended
in humans. All monkeys were found to be nega-

J O

140

THE JOURNAL-LANCET

tive, including those later proved to have tuber-
culosis. Treatment was started on the sick mon-
keys using the same doses of streptomycin and
isoniazid that are recommended for humans.
The epidemic continued and the treatment was
ineffective. Dr. Byron W. Bernard, chief veter-
inarian of the Zoological Society of Cincinnati,
and Dr. Leon H. Schmidt, Christ Hospital, In-
stitution of Medical Research in Cincinnati, were
contacted. The Cincinnati Zoo had had a simi-
lar epidemic, and Dr. Schmidt had done con-
siderable research in tuberculosis using monkeys
as laboratory animals. On advice of these men,
certain tuberculosis control measures were put
into effect. The two remaining monkeys sus-
pected of having tuberculosis are now well, and
no other cases have occurred for over a year.
Recommendations are as follows :

1. All zoo attendants should have pre-employment
chest x-ray films taken, and all employees of the park-
should have their chests x-rayed annually.

2. Whenever any animal becomes ill, especially with
respiratory infection, he should be removed from the
general zoo quarters and placed in isolation. Here, his
condition can be more easily diagnosed and treated.

3. Whenever an epidemic of tuberculosis is suspected,
all monkeys should be given a tuberculin test with old
tuberculin up to at least 1 to 10 dilution, which is 100
times stronger than the usual recommended dose for
humans. All positive monkeys should either be destroyed

or, if they are of sufficient value, treated. Monkeys under
treatment should be given INH (isoniazid), the dose
being 10 mg. per pound of body weight per day, which
is approximately 5 to 10 times the recommended dose
for humans. As a preventive, all other monkeys in the
zoo should be placed on 1/2 of this dose (5 mg. per
pound of body weight ) to be continued indefinitely.

CONCLUSION

The incidence of tuberculosis in animals is rough-
ly proportionate to the incidence of the disease
in man. Control of tuberculosis in animals de-
pends upon its control in man.

Several years ago, coinciding with the use of
the new antituberculosis drugs, it was freely pre-
dicted that tuberculosis will soon be eliminated.
Now, it appears that this prediction may be pre-
mature. The fall in the mortality rate is leveling
off, and, in many parts of this country, the in-
cidence, as measured by newly reported cases, is
actually increasing. The contagious, noncoopera-
tive patient is still with us, and, thanks to the
same miracle drugs, he is much more dangerous,
because incomplete or interrupted treatment has
increased his activities in time and breadth. Many
appeals have been made to do something about
this situation with little effect. It seems that many
fatal accidents must occur at a dangerous inter-
section before a traffic light is erected.

BIBLIOGRAPHY

1. Beattie, Margaret, and Nicewonger, R.: Bovine tubercle

bacilli in sputum. Am. Rev. Tuberc. 45:586, 1942.

2. Benson, R. E., Fremming, B. D., and Young, R. J.: Tuber-
culosis in monkeys. Am. Rev. Tuberc. 72:204, 1955. 18.

3. Brooke, W. S.: The vole acid-fast bacillus: 1) Experimental

studies on a new type of mycobacterium tuberculosis. Am. Rev.
Tuberc. 43:806, 1941. 19.

4. Carmichael, J.: Bovine tuberculosis in the tropics, with
special reference to Uganda, part I. J. Comp. Path. & Therap. 20.
52:322, 1939.

5. Cumming, W. M.: Pulmonary tuberculosis in dairy-farm 21.

workers and others coming in contact with cattle; type of
causal organism in 14 cases. Tubercle 14:205, 1933.

6. Dobson, N.: Tuberculosis of cat. J. Comp. Path. & Therap. 22.
43:310, 1930.

7. Feldman, W. H., and Code, C. F.: Tuberculosis in dogs, 23.
with report of a case in which surgical procedures may have
influenced the pathogenesis. J. Tech. Methods 22:49, 1942.

8. Feldman, W. H.: Animal tuberculosis and its relationship to 24.

the disease in man. Ann. New York Acad. Sc., 48:469, 1947.

9. Feldman, W. H., and Moses, H.: Human tuberculosis in a

bovine; case report of a spontaneous infection in an adult 25.
bovine. Am. Rev. Tuberc. 43:418, 1941.

10. Francis, T.: Tuberculosis in the dog. Am. Rev. Tuberc. 73: 26.

748, 1956.

11. Fremming, B. D., and others: Maintenance of a colony of
tuberculous monkeys. Proc. AVMA, 92nd annual meeting,

August 1955, pp. 219-222. 27.

12. Griffith, A. S.: Types of tubercle bacilli in equine tuber-
culosis. J. Comp. Path. & Therap. 50:159, 1937.

13. Grosso, A. M.: Tuberculosis in monkeys in Buenos Aires Zoo. 28.
Gac. vet., B. Aires, 18:9, 1956.

14. Hawthorne, V. M., and Jarrett, W. F. H., and others: 29.

Tuberculosis in man, dog, and cat. Brit. M. J. 2:675, 1957.
Abstracted in J.A.M.A. 166:287, 1958.

15. Hull, T. G.: Diseases transmitted from animals to man, in

Tuberculosis bv W. H. Feldman. Springfield, Illinois: Charles
C Thomas, 1955, p. 5.

16. Lovell, R., and White, E. G.: Naturally occurring tuber-
culosis in dogs and some other species of animals. I. Tuber-
culosis in dogs. Brit. J. Tuberc. 34:117, 1940. II. Animals
other than dogs. Brit. J. Tuberc. 35:28, 1941.

17. Mallick, S. M., Aggarwal, H. R., and Dua, R. L.: Investi-

gation into incidence and type of tuberculous infection in
cattle at Amritsar, with special reference to human infections.
Indian M. Gaz. 77:668, 1942.

Medlar, E. M.: Pulmonary tuberculosis in cattle; location
and type of lesions in naturally acquired tuberculosis. Am.
Rev. tuberc. 41:283, 1940.

Myers, J. A.: Man’s Greatest Victory over Tuberculosis.

Springfield, Illinois: Charles C Thomas, 1940.

Myers, J. A., and Dustin, Virginia L.: Cattle get TB from
People. Hoard’s Dairyman, Fort Atkinson, Wis., Dec. 10, 1947.
Plummer, H. C., and Brown, M. I.: A study of acid fast
bacilli recovered from tuberculous monkevs. Canad. J. Pub.
Health. 45:296, 1954.

Riser, W. H., and Karlson, A. G.: Tuberculosis in the dog.
J. Am. Vet. M. A. 129:118, 1956.

Schmidt, L. H.: Some observations on the utility of simian

pulmonary tuberculosis in defining therapeutic potentialities
of isoniazid. Am. Rev. Tuberc. Supp. 74:138, 1956.

Schmidt, L. H., Hoffmann, R., and Steenken, W., Ir.:
Pathogenicity of atypical chromogenic mycobacteria for the
Rhesus monkey. Am. Rev. Tuberc., 75:169, 1957.

Scott, H. H.: Tuberculosis in man and lower animals. Med.
Res. Council Special Report Series. 149:1, 1930.
Stadnichenko, A. M. S., Sweany, H. C., and Kloeck, J. M.:
Types of tubercle bacilli in birds and mammals; their inci-
dence, isolation and identification. Am. Rev. Tuberc. 51:276,
1945.

Stamp, J. T.: A review of the pathogenesis and pathology
of bovine tuberculosis with special reference to practical prob-
lems. Vet. Rec. 56:443, 1944.

Tice, F. J.: Man, a source of bovine tuberculosis in cattle.
Cornell Vet. 34:363, 1944.

Wood, A. J., and Kennard, M. A.: The feeding, housing and
management of a small monkey colony. Canad. J. Comp.
Med., 20:294, 1956.

PERSONAL COMMUNICATIONS TO THE AUTHOR

1. Dr. R. H. Runde, medical director, Peoria County Sanatorium
District.

2. Dr. R. B. Hollingshead, veterinarian, Glen Oak Park Zoo.

3. Mr. Richard Houlihan, director, Glen Oak Park Zoo.

4. Dr. James H. Steele, chief, Veterinary Public Health, U. S.
Public Health Service.

APRIL 1958

141

Edward A. Meyerding, M.D

Physician, Educator and Friend

By J. ARTHUR MYERS, M.D.

When Dr. Henry M eyerding came to the
United States from Germany in the 1850’s,
he located in New Ulm, Minnesota. He later moved
to St. Paul, where he not only practiced medicine
but also was assistant health commissioner and
served numerous terms on the school board. Later,
as a member of the state legislature, he supported
hills in the interest of public health, education, and
general welfare.

Born on Christmas Day, 1879, Edward A. Meyer-
ding had the advantages of observing his grand-
father and learning about his education, public
health, and practical medical work. As children, he
and his brother Henry were inspired to contribute
in a similar manner. Edward no sooner graduated
from the Mechanic Arts High School in St. Paul
in 1898 than he entered the University of Minnesota
School of Medicine and graduated in 1902. For the
next seven years, he was engaged in private practice.
He was especially interested in eve and ear work,
so, in 1909, he enrolled for graduate studies at the
Manhattan Eve, Ear and Throat Hospital and at
Bellevue Medical Hospital, New York City. From
there he attended the Harvard Graduate School and,
later, took special training in Chicago and Boston
and, still later, in Paris.

Upon returning to St. Paul to engage in this
specialty, his services were sought by the superinten-
dent of schools, and he became the first school
physician in that city. Among numerous other activ-
ities, he worked to provide special education for
children with defective hearing, vision, and speech,
as well as crippled and mentally slow individuals.
Results were so remarkable that by 1914 he was
made director of hygiene of the St. Paul schools.

Dr. Meyerding entered active military service in
the Medical Department of the United States Army
in April 1917. He was well prepared because, since

1898, he had served as a commissioned officer in
various capacities in the Minnesota National Guard
over a period of ten years. He was discharged in
1919 with the rank of major. On September 13,
1924, he was commissioned lieutenant colonel in the
Medical Corps of the United States Army and ad-
vanced to colonel on April 17, 1935. Since July 24,
1941, he has been colonel, inactive.

When he resigned from his school position in
1924, his departmental staff had increased from 1
nurse and himself in 1909 to 18 school nurses, 1
chief nurse, 5 provisional nurses, 3 oral, hvgienists,
6 medical examiners, and 37 teachers of special
classes.

In 1924, he was elected executive secretary of the
Minnesota Public Health Association and secretary’
of the Minnesota State Medical Association. This
was a splendid arrangement as it brought the two
organizations to a better understanding of one an-
other. During the next thirteen years, they were
developed beyond any height that had ever been
anticipated. Bv 1937, each had become large
enough to require a full-time secretary. Dr. Mever-
ding then resigned from the State Medical Associa-
tion position in order to devote his entire time to
the Tuberculosis and Health Association.

In 1924, 1,708 persons were reported to have
died from tuberculosis in Minnesota. This was a
mortality rate of 69.5 per 100,000. The 1 state and
14 county sanatoriums \\rere filled to capacity, and
many persons were ill in their homes for lack of
sanatorium beds. Dr. Meverding was determined
from the beginning to stop this terrible onslaught of
a disease which was already known to be prevent-
able. His first activity was to develop a compre-
hensive program. He then traveled hundreds of
thousands of miles bv automobile to effect good
organization of the people in every nook and cranny

142

THE JOURNAL-LANCET

of the state. He repeatedly visited these organiza-
tions to make certain a uniform program was main-
tained in all of the counties.

Being secretary of the State Medical Association
provided him an opportunity to promote tubercu-
losis work among the physicians throughout the
state. He organized a team of medical speakers,
and the local medical societies arranged programs
devoted entirely to talks on tuberculosis. Dr. Mever-
ding usually conveyed this team in his private auto-
mobile. Some of the meetings were as far awav
as 300 miles, and not infrequently the trips started
at noon, and, after the evening medical meeting, the
return trip required the remainder of the night.

Early and accurate diagnosis was given a promi-
nent place in the program. The specificity and accu-
racy of the tuberculin test were well-established.
Dr. Meverding, therefore, launched a tuberculin test-
ing program. It was accompanied bv an educational
campaign to inform the citizenry of the state of the
value of the test in locating persons who were
harboring tuberculosis germs and the importance of
periodic x-rav films of the chests of all persons who
reacted to the tuberculin test.

In 1932, he arranged for tuberculin diluted and
ready for administration to be delivered without
cost to physicians throughout the state who de-
sired it. This was on a demonstration basis, and
it proved so effective that the State Board of Health
adopted it in 1937 and has continued this fine
service to the medical profession.

In the early 1920’s, it had been recognized that
x-ray films usually reveal evidence of evolving gross
lesions in the lungs of tuberculin reactors earlier
than any other phase of examination. It was also
known that such lesions appear only in the lungs
of persons who react to tuberculin. Therefore, x-ray
film inspection should be routine procedure in all
chest examinations of tuberculin reactors and peri-
odical thereafter for those whose chests appeared
clear on initial examination.

A serious problem concerning the production of
satisfactory x-ray films was encountered. Many
physicians throughout the state had first class x-ray
equipment but were not producing satisfactory films.
Dr. Meverding made available an expert technician
who spent time in their laboratories demonstrating
satisfactory film technic.

In the early 1940’s, when the wave of enthusiasm
for mass photofluorographic surveys reached Minne-
sota, it had previously been established bv actual
studies in this state that such a program had in-
surmountable limitations, making it far inferior to
the procedures already in vogue. However, the pro-
motors of photofluorographic surveys created so
much enthusiasm that established facts made no
impression, and the surveys were introduced. Dr.
Meyerding took advantage of the opportunity to
cooperate purely on the basis of a device for bring-
ing the disease to the attention of the public and
better informing the people. However, tuberculin
testing in the schools and elsewhere with the usual

program was continued by his association and its
allies without interruption while the mass photo-
fluorographic surveys proceeded. In only a few
years, mass photofluorographic surveys ended ex-
cept in a few special groups, and the regular pro-
gram continued.

Dr. Meyerding has constantly emphasized the
importance of transmitting information about tuber-
culosis to professional as well as lay citizens. For
example, in 1928, he inaugurated refresher courses
in tuberculosis for practicing physicians. The
courses were usually held in sanatoriums. Fore-
noons and afternoons were devoted to examining
patients and demonstrating the best diagnostic and
treatment procedures of the time. The importance
of isolation to prevent infection of others was especi-
ally emphasized. Immediately following luncheon
and dinner, lectures were presented. Later in the
evening, a lecture was usually given for the entire
citizenry of the area. These courses were nearly
always oversubscribed.

In 1946, he arranged a three-day course in tuber-
culosis for lay workers at the Continuation Center,
University of Minnesota. This covered much im-
portant information about tuberculosis, which lay
persons could transmit to their co-workers through-
out the state. Those in attendance declared the
course so valuable that it was repeated the next year
with the same result. Ever since, this has been an
important educational activity.

In 1934, he arranged for the State Medical As-
sociation and the Tuberculosis Association to co-
operate in organizing a series of lectures on var-
ious health subjects, with special emphasis on tuber-
culosis, to be given bv physicians well qualified
in their respective fields. By 1938, four such lec-
tures were being presented annually in 20 colleges.
A tremendous amount of other educational work
has been done through pamphlets, newspapers,
magazines, radio, and television, as well as the
monthlv official publication of the organization,
Everybody’s Health.

Throughout the decades, Dr. Meyerding has made
the facilities of his organization available to, and
has worked in close cooperation with, about 40 other
organizations.

In 1940, the State Board of Health, the State
Medical Association, and the State Tuberculosis
Association decided to initiate a plan wherebv en-
tire counties might be accredited on the basis of
accomplishment in tuberculosis control. Standards
were set up and, whenever a county qualified, an
official certificate signed bv officials of these organi-
zations and the governor of the state was presented.
Lincoln Countv, the first to qualify, received its cer-
tificate on December II, 1941 (figure 1). In this
accreditation of counties, Dr. Meverding played
a large role. The program provided educational
opportunities that nothing else had done. The pro-
ject continues to operate and on April 1, 1958, 67
of the 87 counties had been accredited. Most of the
remainder are about to qualify.

APRIL 1958

143

MINNESOTA

DEPARTMENT OF -HEALTH

MINNESOTA STATE
MEDICAL ASSOCIATION

TfJm il fo (Oerfi^y fU

It in coin ©ount^J

Has fulfilled the minimum requirements of the Minnesota Department of
Health and the Minnesota State Medusa l Association for the control of Tuhercu-
losis, in consideration of which this award is granted and the County designated

A TUBERCULOSIS ACCREDITED COUNTY

Fig. 1. First certificate issued for accomplishments in tuberculosis control.

TB

ORTALITY RATE
Per 100.000

| | 10 or lea

[v]l0 + to!S

U 15+10 20
■ 20+10 25
[3 25+ to 30
SB 30+10 35

Hj 35 and up

Fig. 2. Map of Minnesota showing average
tuberculosis mortality rates in each county
over the five-year period, 1936 to 1940.

Fig. 3. Map of Minnesota showing average tu
berculosis mortality rates over the five-vear per
iod. 1952 to 1956.

144

THE JOURNAL-LANCET

Fig. 4. First certificate issued for tuberculosis control work in progress.

In 1940, a countv outline map of Minnesota was
produced showing the average tuberculosis mortal-
ity in each countv for the past five years. This was
widely distributed throughout the state and resulted
in the manifestation of a great deal of local pride
among citizens. The counties with a mortality rate
of 35 or more per 100,000 were indicated in black.
As a result of this map, so much interest was created
in the solution of the tuberculosis problem that activ-
ity in the program of eradication rapidly increased.
Thereafter, Dr. Meverding prepared a new map
every two years. Comparison of the maps over the
years enabled each citizen to visualize the effective-
ness of work in his countv as far as mortality was
concerned (figures 2 and 3).

When the Committee on Tuberculosis of the
American School Health Association decided to
certify schools with reference to tuberculosis activ-
ities in progress, a subcommittee of physicians was
appointed in each state. Minnesota was chosen to
make the initial demonstration, largely because its
workers had continued extensive tuberculosis work
in the schools over such a long period, and Dr.
Meverding was appointed chairman of the Minne-
sota subcommittee. He enthusiastically proceeded
with this project and with the other members of his
subcommittee made the demonstration a complete
success. The first official certificate was issued to
the schools of Northfield on October 15, 1945 (figure
4). This project also took advantage of local pride
and rapidly extended throughout the state. More
than 3,000 certificates have now been issued, and
many other schools are about to qualify. This pro-
ject has been adopted by several states with the
same good results. Wherever employed, this pro-

gram has stopped the tuberculous teacher, bus
driver, or other employee from spreading tubercle
bacilli to fellow workers and students. Moreover,
it has resulted in more activity and a more complete
program than any other procedure employed in the
state.

When Dr. Harold S. Diehl, dean of medical
sciences, University of Minnesota, instituted the
hospital admission examination for tuberculosis at
the University Hospital in 1935, Dr. Meverding
was immediately enthusiastic, and, through his or-
ganization, he began to inform physicians, hospital
administrators, nurses, and all concerned through-
out the state of the value of this procedure. There-
fore, it was not by chance that bv 1958 all but one
hospital in the twin cities required admission ex-
aminations, and 80 per cent of all persons entering
hospitals throughout the entire state now receive
such examinations.

Dr. Meverding is an indefatigable worker.
Throughout the years, he has devoted far more time
to his work than his position demanded. This ac-
counts in part for so many outstanding achieve-
ments. He has always had more than usual ability
in selecting staff workers. They are too numerous to
present individually in this sketch. Suffice it to say,
they have contributed mightily to the success of his
program. It has been said that the name Meverding
is synonymous with Christmas Seals in Minnesota.
Since becoming executive secretary of the Minnesota
Tuberculosis and Health Association, he has been
fully aware of the educational value of Christmas
Seals. In 1922, of all states, Minnesota ranked 12th
in the per capita sale of seals. With Dr. Mever-
ding’s efforts, Minnesota had reached eighth place

APRIL 1958

145

in 1928, fourth in 1942, third in 1947, and second in
1948. This position has since been maintained.

The tuberculosis mortality rate decreased from
69.5 per 100,000 (1,708 deaths) in 1924 to 3.6 (117
deaths) in 1956. The number of clinical cases de-
creased, so several smaller sanatoriums have been
closed, and the remainder are operating at about
50 per cent capacity. Tuberculosis infection has de-
creased among citv grade school children from 47
per cent in 1926 to 4 per cent in 1954. There are
now many schools in rural areas with no tuberculin
reactors.

Dr. Meyerding holds membership in county,
state, and national medical associations. He was an
organizer of the Minnesota Trudeau Society and
holds membership in the American Trudeau Society
and the National Tuberculosis Association. He is a
fellow of the American College of Chest Physicians.
In 1938, he was president of the Mississippi Valley
Conference on Tuberculosis. He has served on
numerous committees of that organization and of the
National Association of Tuberculosis Secretaries. In
1942, he was selected as Man of the Year bv the
4-H Clubs, and, in 1956, he received the William
G. Anderson award by the American Association for
Health, Physical Education, and Recreation.

It has been my privilege to travel extensively
with Dr. Meyerding bv automobile in the state
and by rail and airplane to many of the large centers

of the country attending conventions. We have
conferred hundreds of times concerning methods of
attacking and destroying the tubercle bacillus.

Throughout this intimate association of more than
a third of a century, he has constantly proved his in-
tegrity, sincerity, and ability. He always manifested
a strong courage of his convictions. Anv individual
or group who threatened to harm his well-thought-
out program or the cause for which he worked had
to be prepared to do battle. His fight against tuber-
culosis took precedence over everything else in his
life. He placed his organization behind every worth-
while tuberculosis control activity and has been re-
sponsible for the completion of many projects which
otherwise would have been left unfinished.

To Ed Meyerding belongs much credit for out-
standing achievement in tuberculosis control. Much
that is being accomplished today would not be
possible without the years of preparatory work
which he directed. When he retired on April 1,
1958, one of the most active and productive careers
in the fight to exterminate tuberculosis in this coun-
try’s history was closed. For well-nigh a third of a
centuryi he was one of America’s most powerful
forces against this disease. Fortunately, fires he
kindled in many others are still burning brightly.
From them others will be lighted, and, thus, the
goal so clearly visualized bv Dr. Meverding mav
be realized bv other generations.

Plans are under way for the Special Issue which will be published in June
in honor of the eleventh World Health Organization Assembly meeting to be
held May 26 through June 14 in Minneapolis. Serving as a channel of com-
munication on an international basis, the June issue of The Journal-Lancet
will afford an unusual opportunity to become acquainted with the health prob-
lems of many nations.

The Journal-Lancet is happy to be an avenue of information concerning
the outstanding work of WHO and the important personalities responsible for
this movement.

146

THE JOURNAL-LANCET

Cancet Editorial

Radiation Hazards

The article in this issue entitled “Ionizing Ra-
diation in Medicine — A Useful Tool and a
Hazard,” by Drs. Marvin, Loken, and Mosser is
very timely. This editorial is written to call atten-
tion to their article and to emphasize some aspects
of safe fluoroscopic and radiographic examinations.

Among the group of doctors with whom I am per-
sonally acquainted in this area — Minnesota, North
Dakota, and South Dakota — 2 have died of leu-
kemia within the last five years, undoubtedly due
to too much radiation. One physician died of metas-
tases from a carcinoma of the finger secondary to
radiation damage of the hand because he did not
wear lead rubber gloves during fluoroscopy.

Many patients in the states served by this maga-
zine have had to undergo plastic surgery for radia-
tion damage to the back caused bv too prolonged
fluoroscopic examinations, inadequate filtration in
the fluoroscopic tube, or both. It, therefore, be-
hooves us as doctors to protect ourselves, aides, and
patients from too much radiation.

Film monitoring badges should be worn bv all
personnel in all x-rav departments.

We must not order or perform unnecessary x-rav
examinations, but all indicated radiographic examin-
ations, I believe, can be performed safelv without
danger to the doctor, technician, or patient if the
proper safety precautions are observed.

We must do everything possible to minimize the
total exposure to all concerned. The equipment must
be properly installed with proper lead protection in
the walls and an adequate lead protected booth for
the operator. All equipment should be checked for
radiation hazards by a competent person at periodic
intervals. All radiographic diagnostic units should
contain at least 2 mm. aluminum filter. The smallest
possible cones should be used.

Fluoroscopic units should contain at least 2'A mm.
aluminum filter. Older fluoroscopic units with short
tube tabletop distance should be discarded or re-
built. The fluoroscopist must take sufficient time to
become adequately accommodated. He should use
as small a field as possible at all times and should
not use over 3 to 4 milliamperes of current. The
fluoroscopist must wear rubber gloves and an apron.
The gloves and apron should be checked period-
ically for cracks and leaks. Lead gloves and aprons
provide only partial protection. The fluoroscopist
must, therefore, keep his lead-gloved hands out of
the x-ray beam as much as possible.

A fracture should never be reduced under the

fluoroscope. The patient is exposed to much less
radiation from multiple films, and the doctor who is
reducing the fracture is in no danger. All fluoro-
scopic units should be calibrated to make sure that
the output at the tabletop is not over 10 r per min-
ute. All fluoroscopes should be equipped with a
timer that will shut off the equipment automatically
at the end of three to five minutes.

Films should be substituted for a fluoroscopic ex-
amination whenever possible. Multiple films prob-
ably give more information than a fluoroscopic ex-
amination. When necessary, a very short fluoroscopic
examination can be done, supplemented with films,
so total exposure to the patient is kept at a minimum.

Fluoroscopic examinations in children should be
performed only when a very good indication exists
and then should be completed in as short a time as
possible. Routine fluoroscopic examinations of chil-
dren’s chests should be abandoned. It has been re-
ported that a five-minute fluoroscopic examination
performed on a child doubles the chance that leu-
kemia will develop during his lifetime.

In infants and children with a condition such as
Perthes’ disease or congenital dislocation of the hip
that will require numerous x-ray examinations, the
gonads should be covered with lead on the follow-
up radiographic studies.

X-ray examinations of the abdomen of pregnant
women should not be done, except under extremely
urgent circumstances. X-rav pelvimetry should be
used onlv when it cannot be determined by clinical
means whether the pelvis is adequate or when some
abnormality is suspected. A study in England has
shown that the incidence of leukemia in children is
doubled bv an x-ray pelvimetry examination before
delivery.

The advisability of continuing 70 mm. photofluoro-
graphic chest survey programs has been discussed in
many lay and medical articles in the past few months.
Recently, James E. Perkins, M.D., managing director
of the National Tuberculosis Association, published
a paper on this subject. He concluded that if a per-
son had a 70 mm. photofluorographic chest examina-
tion every year from the age of 15 to 30, he would
have received a total of less than 1 per cent of the
amount of radiation exposure considered safe.

I, therefore, believe it advisable and safe to con-
tinue chest photofluorographic surveys in all areas in
which the vield is significant.

H. Milton Berg, M.D.,
Bismarck, North Dakota

APRIL 1958

147

The Last Tubercle Bacillus

This issue of The Journal-Lancet contains a
highly significant paper entitled “The Tuber-
culin Test” by Dr. Paul S. Dodd and another on
“Tuberculosis from Man to Animals” by Dr. George
D. Morse. They are important to all who visualize
the eradication of tuberculosis and to those who
should acquire such a vision. The authors make it
clear that the attack must be made on all three
pathogenic forms of tubercle bacilli, inasmuch as
each tvpe produces progessive disease in more than
one species. For example, the human type, in addi-
tion to man, causes clinical tuberculosis in such ani-
mals as primates, swine, dogs, and parrots, which
may disseminate their bacilli not only to other ani-
mals but also to people. Since the human type pro-
duces sensitivity of tissues in cattle, it is obvious
that this form must be sought in animals as well as
in people.

Although among the 95 million cattle of this
country, veterinarians and their allies have reduced
the incidence of those harboring tubercle bacilli to
0.156 per cent, cattle are still in considerable danger
of becoming infected from people. Those cattle
which are infected with the human type of bacilli
may react to tuberculin and, therefore, must be
sacrificed even though their lesions do not become
clinical.

The problem will never be solved if tuberculosis
work is limited to human beings, as they may be in-
fected with the bovine tvpe of tubercle bacilli ac-
quired not only from cattle but also from dogs, cats,
swine, parrots, and other animals.

While there are onlv slightly more than two dozen
known cases of authentic clinical tuberculosis caused
by the avian type of tubercle bacillus in man, this
subject has never been thoroughlv investigated.
Therefore, it is possible that the problem is more
serious than has been suspected. The very fact
that definite cases have occurred is sufficient reason
to support the veterinarian’s campaign to eradicate
the avian type of tubercle bacillus. It produces
clinical disease in fowl and other species, such as
swine, and, thus, is a serious economic problem.

This emphasizes the necessity for close coopera-
tion between veterinarians, physicians in human
medicine, and every interested group in making the
all-out eradication attack on the tubercle bacillus.
Failure to do this in the past has been costly in re-
tarding progress.

There are so many diseases transmissible from
animals to people and vise versa that every board
of health and tuberculosis association, state and
local, should have one or more veterinary members.

Veterinarians have led the wav and are so far
ahead of physicians in human medicine in tubercu-
losis eradication that their counsel should be sought
continuously. The example set in Illinois is one
that should be emulated and emploved everywhere.

Dr. Dodd has long been an active member of the
Illinois Tuberculosis Association and has served on
important committees. Now he is president of that
organization. He tells how veterinarians went from
farm to farm through rain, snow, and mud as well
as during clement weather, so that every animal in
a township, county, and state would be tested with
tuberculin. It made no difference whether there was
1 or 50 animals on a farm; all were tested. More-
over, periodic testing of cattle has continued among
the 95 million animals in this countrv despite the
fact that, in some places, such as the upper midwest
states, 5,000 or more tests must be administered to
find one reactor.

When this thoroughly organized program was
introduced on a nation-wide basis in 1917 and pro-
secuted to the nth degree, no such consideration was
given to the tuberculosis problem among people.
Only recently have physicians, nurses, and their
allies organized to visit each home in a township,
a county, or a state to find every person harboring
tubercle bacilli.

In 1917, physicians in human medicine had the
same tools as veterinarians, but they were hampered
bv theories, personal opinions, speculation, and the
like. Fortv years passed (1917-1957) with the veteri-
narian unceasingly promoting his program, while
the physician in human medicine continued to labor
over such questions as what does the tuberculin
reaction mean? which kind of tuberculin and which
method of administration should be emploved? The
threadbare statement “you can slaughter the cattle,
but you can’t slaughter people” was parroted. The
result is that even twenty years of the veterinarian’s
program brought such achievement as to be desig-
nated “man’s greatest victory over tuberculosis,” and
the next twenty vears were no less spectacular. In
1957, onlv 0.156 per cent of the nation’s 95 million
cattle were harboring tubercle bacilli, and apparent-
ly some of them were infected bv their human as-
sociates. Trailing in the far distance is the physician
in human medicine with a record of approximately
33 per cent of the 173 million people harboring
tubercle bacilli, among whom thousands are break-
ing down with clinical disease annually and often
disseminating tubercle bacilli to others.

Only in recent years have a few persons been
able to obtain adequate support to certify schools
with reference to tuberculosis work in progress and,
thus, make them safe from the standpoint of disemi-
nation of tubercle bacilli. Onlv a few have won
support for offering the tuberculin test to people
of all ages on countv-wide or municipal-wide bases
and, in this way, locate all the tubercle bacilli re-
siding in the area and act accordingly.

Veterinarians have shown that there is no short
cut to eradication of tuberculosis. There is no effec-
tive immunizing agent. There is no drug vet avail-

148

THE JOURNAL-LANCET

able to destroy bacilli in the animal or human tissues
such as we have for some other micro-organisms.

If a thoroughly germicidal drug becomes avail-
able, in all probability it will be of no help in
destroying all tubercle bacilli in the bodies of per-
sons now harboring them. Thev are secure in ne-
crotic avascular areas, so that cure of the disease
in the sense of killing all tubercle bacilli in the
bodies of such persons will remain a forlorn hope.

To catch up with the veterinarian will require
longer than forty years, because the life span of
people is much greater than that of domestic ani-
mals and because every infected person must be
kept under close surveillance throughout the re-

mainder of his life span. This means that if we
allow infants to become infected, the period of sur-
veillance must be continued for seventy or more
years on the average.

There is nothing to be gained but much to be lost
in continued procrastination. The onlv method now
available that offers the slightest hope of ultimate
eradication of tuberculosis consists of locating all
tubercle bacilli in both people and animals and out-
witting them until the last one has vanished. The
goal is far off but is attainable bv the methods des-
cribed by Drs. Dodd and Morse.

J. Arthur Myers, M.D.

Minneapolis, Minnesota

Clinical Gastroenterology, by Eddy
D. Palmer, M. D„ F.A.C.P.,
1957. New York: Paul B. Hoeber,
Inc., 630 pages, 216 illustrations.
$18.50.

When anyone writes a book of this
size, the interested reader usually
has three impressions: (1) how much
the author knows about the subject;
(2) how much the author does not
know about the subject, and (3) how
much remains to be learned about it.

The title of this book might well
have been Clinical Gastroenterology
Viewed From the Standpoint of an
Internist. Certainly there are phases
of gastroenterology which could not
be well discussed by anyone other
than a surgeon who affects a special
interest in the alimentary canal and
its appendages.

One cannot read this book with-
out appreciating that its author is a
good observer and an astute clini-
cian. Moreover, it is a very readable
book. The active cooperation of an
experienced surgeon or surgeons in
dealing with some of the disorders
treated in the text would undoubt-
edly have enhanced the value of the
monograph considerably.

How myopic some of the views
of the author are is readily detected
in the section on gastric cancer.
Concerning surgical management,
he says: “Surgical help is required
for the relief of pyloric obstruction,
for control of the unusual cases of
severe hemorrhage, and for what-
ever help is possible in cases of
acute perforation.” Under the cap-
tion of Philosophy of the Gastric
Cancer Problem as it Stands Today,
the writer says: “It seems clear that
we should give up current measures
directed at cure as a bad job now,
without waiting for a more effec-

tive replacement. A degree of emo-
tional and physical comfort is all
that can be promised the patient
at the moment. It at least repre-
sents a retreat from the current
blind track which is necessary be-
fore the right track can be found.
A doctor should consider well his
responsibility to avoid being fright-
ened into unleashing the whole pack
of therapeutic hounds against the
cancer as a way out for himself but
not necessarilv the patient.”

However much we lament the
circumstance that the surgical man-
agement of gastric cancer is not
what it should be, there is after all
a definite accomplishment. When
the writer suggests that 10 to 15
per cent of untreated patients with
gastric cancer survive five years or
more beyond the period at which
symptoms first appeared, he obvi-
ously is recording an experience un-
familiar to most of us who have a
real interest in this problem. A 10
to 15 per cent five-year survival is
the meager accomplishment, which
surgical clinics attacking the prob-
lem vigorously are reporting. And
however small that accomplishment
is, it certainly far surpasses the sur-
vival of patients left to their own
resources. In this clinic, no untreat-
ed patients with gastric cancer have

survived five years after the ap-
pearance of symptoms. This is dan-
gerous philosophy, which the author
of this book is preaching — a cir-
cumstance too which indicates how
much he is in need of active sur-
gical collaboration in a monographic
assault upon the problems of clin-
ical gastroenterology.

It is an easy matter to detect a
few weaknesses in a monograph
covering so wide a range. It is in
many respects a very informative
text, interestingly written, which
will have a wide appeal especially
among those who do not expect too
much of surgery or of surgeons.

Owen H. Wangensteen, M.D.

•

Fundamentals of Clinical Neuro-
physiology, by Paul O. Chat-
field, M.D., 1957. Springfield,
Illinois: Charles C Thomas, 392
pages. $8.50.

The author states in the preface that
the book is meant to present a global
view of the subject for the use of
nonspecialists in the field of neuro-
physiology. This view, he says, will
be influenced by the author’s vary-
ing interests in the different sub-
jects. This is, of course, true of any
book written by only one author.

In this case, however, we find a
fairly well-balanced emphasis on all
the important parts of neurophysi-
ology. The fundamental principles of
the subject are very clearly stated in
a didactic and stimulating fashion.

The problems of nerve conduction,
propagation of impulse, and synaptic
transmission are discussed at the be-
ginning. This is followed by a review
of the physiology of receptor organs
in general and in particular. One
chapter deals with the physiology of

APRIL 1958

149

skeletal muscle, briefly mentioning
the technic of electromyography and
discussing in a synthetic and clear
way the probable functions of the
small fiber system of the ventral
roots.

The rest of the book is devoted
to the central nervous system, start-
ing with the spinal reflexes, postural
coordination, and going on to dis-
cuss the physiology of the vestibular
apparatus, basal ganglia, and cere-
bellum and cerebral cortex, includ-
ing thalamocortical relationships.
Here, the specific and diffuse pro-
jection systems are mentioned, and
the different steps that lead to our
actual knowledge of these systems
are summarized. The final chapter
is a brief review of the facts concern-
ing the central representation of the
autonomous nervous system and the
neurophysiology of emotions.

The chapter on the nervous con-
trol of breathing is particularly im-
portant. This part needs a special
mention, not only because of the
clinical importance of the matter in
any specialty of medicine or phys-
ology, but also because of the
author’s vast knowledge of the sub-
ject. Dr. Chatfield has published
several papers on his experimental
findings regarding this problem, and
this chapter is a clear and intelligent
synthesis of the work of many out-
standing workers.

References are listed separately at
the end of each chapter, and the in-
dex of authors is long and quite
complete, considering the size of this
volume.

One criticism that can be made is
about the fact that proportionally
much greater emphasis is placed on
the first part of the book dealing
with peripheral nerve and general
neuro- and electrophysiologic prob-
lems than on the physiology of the
central nervous system, especially in
regard to the cortex, thalamus, and
basal ganglia. Interesting new find-
ings like those referring to the role
of dendritic potentials in the spon-
taneous cortical activity are barely
mentioned. Many interesting possi-
bilities about the role of the diffuse
projection system of the thalamus are
not extensively treated.

This, however, is probably in
keeping with the general scope of
the book. We can definitely say that
the goal of producing a short, clear,
and very well presented picture of
the physiology of the nervous sys-
tem for the purpose of teaching stu-
dents and newcomers to the field
was amply accomplished. The author
himself tells us in the preface that
the problems for which answers are
not yet clear are deliberately omitted.
It is only because we wanted to
read more about them in the same
clear and simple style in which Dr.
Chatfield writes throughout his book,
that we found ourselves missing a
more complete discussion of certain
central nervous system problems.

This book is definitely worth-
while for teachers and those inter-
ested in learning about the nervous
system.

Fernando Torres, M.D.

•

The Early Diagnosis and Treatment
of Acoustic Nerve Tumors, by J.
Lawrence Pool, M.D., and Ar-
thur A. Pava, M.D., 1957. Spring-
field, Illinois: Charles C Thomas,
161 pages. $5.50.

This monograph represents a review
of the acoustic nerve tumors in which
the authors utilize 6 previously re-
ported series of cases in addition to
a series of 122 cases of acoustic nerve
tumors operated upon at the Neuro-
logical Institute of New York during
the years 1944 to 1955.

History, terminology, histogenesis,
pathology, and incidence are all
dealt with categorically, albeit, in
some cases, briefly. Symptoms and
signs are chronologically reviewed
with emphasis upon the preponder-
ance of primary complaints and find-
ings referable to eighth nerve in-
volvement. The incidence and chron-
ologic order of appearance of head-
aches, cerebellar involvement, cranial
nerve involvement, increased intra-
cranial pressure, and terminal in-
volvement are thoroughly discussed
and a complete description of the
variation of signs and symptoms
attendant upon these conditions is
included. Diagnostic procedures,
such as skull roentgenograms, air en-

cephalography, arteriography, elec-
troencephalography, examination of
the cerebrospinal fluid, and audio-
metric and vestibular tests are de-
scribed, and the authors comment on
their opinion of the value of each
procedure. There is a section contain-
ing the histories of 6 atypical cases
in the author’s series and another
concerning differential diagnosis.

However, the most interesting and
valuable part of the monograph is
that devoted to discussion of the
surgical approach to the neoplasm.
The authors present a rather con-
vincing case for attempts at total
removal whenever possible. The en-
tire surgical technic is elaborated
upon and is accompanied by a num-
ber of illustrations. Moreover, sev-
eral subtle refinements of surgical
technic, such as partial resection of
the cerebellum and sparing of the
facial nerve, are described.

The authors conclude with sections
on postoperative management; mor-
bidity, including immediate post-
operative complications and later
sequelae, a discussion of the tech-
nic of facial nerve anastomosis; and
an analysis of the mortalities in their
series.

David F. Mendelson. M.D.

•

It Pays to Be Healthy, by Robert
Collier Page, M.D., 1957. New
York: Prentice - Hall, Inc., 285

pages. $4.95

It pays to read “It Pays to Be
Healthy.” This unique book de-
scribes in an excellent manner mod-
ern medicine in modern industry. Bv
paying attention to the health of the
individual, benefits come to both
employee and employer. Dr. Page
supports his statements by interest-
ing case reports which add a great
deal to the value of the book.

The last chapter on retirement is
especially good and is very helpful
in preparing for that day when the
tempo of life must change.

This book is to be recommended
with enthusiasm to physicians, pa-
tients, and all people interested in
the preservation of health.

Arnold S. Anderson, M.D.

150

THE JOURNAL-LANCET

Section on PAIN

Comments concerning this Section, criticisms, or suggestions for papers will be most
welcome. Physicians are cordially invited to submit articles pertaining to pain for
consideration. All inquiries and manuscripts should be sent to Dr. John S. Lundy,

102 Second Avenue Southwest, Rochester, Minnesota, or to the Editorial Depart-
ment, The Journal-Lancet, 84 South Tenth Street, Minneapolis, Minnesota.

Pelvic Pain in Women— a Universal Problem

G. F. DOUGLAS, M.D., G. F. DOUGLAS, JR., M.D,

G. C. DOUGLAS, M.D., W. W. DOUGLAS, M.D., and
SARAH F. DOUGLAS, M.S., M.T.

Rirmingham, Alabama

This title indicates that, not only the gyne-
cologist and obstetrician, but the internist,
urologist, proctologist, and general surgeon are
concerned with the problem of pelvic pain in
women.

Nerves that supply the ovary are derived from
the renal and aortic plexuses and accompany
the ovarian vessels in the tissue of the suspensory
ligament of the ovary. Embryologically, they
arise high in the abdomen and receive their
nerve supply from a source other than the pelvic
viscera. Pain of ovarian origin is often due to
the stretching of the covering of the ovary, which
disturbs circulation. As a rule, tumors of the
ovary, either benign or malignant, cause very
little pain in their incipiency.

Pains originating in the ovary, such as mittel-
schmerz, should be diagnosed, particularly if
this pain comes about the middle of the cycle
or the ovulation period. The gynecologist should
be a skilled diagnostician, for his diagnostic acu-
men will enable him to treat the pain wisely
rather than to do radical surgery early.

Tumors of uterine origin are, as a rule, asymp-
tomatic. When symptoms do arise, they are prob-
ably due to pressure on and adherence to sur-
rounding structures or from secondary changes
in the tumor itself.

Carcinoma of the body of the uterus or of the
cervix rarely causes pain until lesions have me-
tastasized or the contiguous nerve structures

From The Department of Gynecology, Medical
College of Alabama, Division of the University of
Alabama, Birmingham.

have been involved. One of the frequent causes
of abdominal pain may be from a postabortal
process which could involve the uterus primarily.
Not the rule, but, in some instances, considerable
pain follows procidentia, such as discomfort in
the lower pelvis. Associated with this there may
be an enteroptosis or descent of the pelvic viscera
which causes pulling on the intra-abdominal con-
tents with some discomfort.

Painful menstruation, or dysmenorrhea, is a
symptom rather than a true pathologic finding or
cause. The cause of this abnormal manifestation
of pain should be ferreted out very carefully by
a study of the different systems — neurologic,
gastrointestinal, and urologic — and other so-
matic factors. After all of the factors have been
ruled out, and, if the pain is neurogenic in origin,
an excision of the superior hypogastric plexus
of nerves, such as done in Cotte’s operation, often
gives complete relief. Rut, if there are causes
outside the uterine cavity or other pathology,
we need not expect this operation to produce a
cure. The so-called membranous type of dysmen-
orrhea is usually characterized by severe pain
and the passage of shreds in the menstrual blood
which, at times, amount to a complete cast of the
uterine body.

One of the severe types of pain in the pelvis
is that of ruptured ectopic pregnancy. Of course,
this condition occurs most frequently in the fal-
lopian tubes and can rarely be diagnosed by the
catastrophic pain at the time that rupture takes
place. One of our more simple diagnostic pro-
cedures is cul-de-sac tapping by which the blood
obtained does not clot. This finding, as a rule,

APRIL 1958

151

Section on PAIN

leaves very little doubt concerning the diagnosis
if other symptoms have preceded it, such as
pain, shock, skipping a period for a short time,
and so forth. When considerable loss of blood
accompanies this disturbance, it is well to obtain
a determination of the prothombin time which, if
excessively prolonged, may be combated by the
intravenous administration of vitamin K. Trans-
fusions of whole blood may be necessary. The
treatment of choice is immediate surgery.

A condition that should not be overlooked in
pain of the pelvis, which might be more of a
chronic nature, is the varicocele or the vari-
cosities of the veins about the broad ligaments.
This occurs much more frequently than is cor-
rectly diagnosed. When varicosities are present,
a thrombophlebitis often originates in the pelvis
and then extends into the legs. The operation
for varicocele provides a simpler and safer
method of relieving the pelvic pain than many
other accepted operative measures. So, if a cor-
rect diagnosis can be made early, the patient will
probably be relieved of pain without requiring
much more hazardous surgery.

Pelvic pain is frequently associated with pelvic
lesions in which an ovarian cyst is found, sudden
hemorrhage accompanying rupture of ectopic
pregnancy, rupture of a corpus luteum cyst in
which bleeding follows, or pelvic inflammation.
In a study at the Mayo Clinic of pelvic pain as
related to endometriosis, it was found that 54
per cent of the patients with pelvic endometriosis
had no pain. Some of the rarer findings in the
pelvis should not be overlooked. You may have
actinomycosis along with granulomatous disease
of the pelvis. I would pause for a minute to call
attention to the occasional case of ectopia of
the ureters distal to the internal urethral sphinc-
ter at which there is continous leakage. It is
congenital in origin and is often overlooked
until a study is done.

Abnormal vaginal bleeding not associated with
pregnancy should not be disregarded. Vaginal
examination should be done when the patient
presents herself to the physician with a history
of bleeding, rather than later when the period
has ceased. Oftentimes the bleeding is due to
a carcinoma of the cervix or of the fundus. If
diagnosed at once, the patient’s life can probably
be saved, whereas, if deferred, she has no chance
of recovery.

Different individuals have very different de-
grees of threshold levels of discomfort. Severe
pain to one individual might be discomfort to
another, so that, in evaluating the degree of

severity, we must have some idea of the pain
threshold of the individual.

Chronic residual pelvic inflammation of the
reproductive structures may provoke pain over
the years. The differentiation of acute salpingitis
and appendicitis is not always easy, and it is
generally believed that chronic appendicitis does
not occur nearly as frequently as was formerly
thought. In many instances, pathology other
than the appendix is involved. For example, pain
in the urinary tract might be diagnosed appendi-
citis, whereas it might be pvelitis, ureteritis,
stricture of the ureter, or, in some instances, a
stone in the urinary tract. Finallv, a pyogenic
type of pelvic inflammation usually involves the
serosa and wall of the fallopian tube, less often
the mucosal lining.

In our endeavor to differentiate or arrive at a
proper etiology of the pain in the fallopian tubes,
we should not overlook tuberculosis, for this con-
dition occurs more often than we realize. The
per cent of tubercular salpingitis, as a causitive
Factor in sterility studies, differs in various parts
of the country. Some say it occurs as often as 5
per cent. These statistics are Dr. Albert Shar-
man’s of Glasgow, Scotland. However, in many
places, it is no more frequent than to 1 per cent
or 1/2 per cent. In other countries, the statistics
run as high as 15 to 20 per cent. However, with
the eradication of tuberculosis of the chest and
other portions of the bodv, one would naturally
expect tubercular salpingitis to decrease.

In making a differential diagnosis of a rup-
tured ectopic pregnancy with other causes, in
probably 80 to 90 per cent of the cases, the
patient has missed her menstrual period. This
may have been for two weeks, or six to eight
weeks, but a good or satisfactory history of
menstruation and other factors often aid in a
correct diagnosis.

As stated before, an ovarian neoplasm does
not always produce early pain, but, if it is a
solid tumor, it should be regarded as possiblv
malignant and warrants an early operation.

We should not overlook the so-called somatic
abdominal pelvic pain. A number of people
come under this category, but, certainly, thev
should not be classified as such until all known
pathology that may be present has been ruled
out.

Certain individuals with pelvic pain can be
relieved by either sympathectomy, as previouslv
stated, or intraspinal alcohol injections. The
latter is given more commonlv with the intract-
able pain associated with carcinoma of the

152

THE JOURNAL-LANCET

Section on PAI N

uterus, particularly of the cervix. The pelvic sym-
pathectomy or the removal of a part of the sym-
pathetic nerve plexus or presacral neurectomy, in
which the presacral or the superior hypogastric
plexus is removed, is not a serious operation.
However, proper diagnosis should be made be-
fore operating or the results will be disappoint-
ing.

In a study of 5,539 patients, Guerriero and
Stuart found the chief complaint of pain was in
the region of the pelvis. These men stated that
there were 1,371 cases either of gynecic origin or
simulating such pain. Five hundred and seventy
one, or 41.6 per cent, of these women actually
had pelvic pain of other than gynecic origin, and
800, or 58.4 per cent, had gynecic states to ex-
plain the origin of their pain. They stated that
only 10.6 per cent of their cases required major
surgery for relief of their pain.

The management of severe dysmenorrhea and
pelvic pain is a problem now as it was in 1852
when Marion Sims stated “of all the newly found
drugs, not any is of much value to the woman
with severe pain except laudanum.” In other
words, he was stating that a drug to relieve
women of pain was considered, rather than a
diagnosis of its cause.

As late as 1921, Leriche made a complete study
of the pelvic sympathetic system in its relation to
pelvic pain, and he developed the procedure of
periarterial sympathectomy of the internal iliac
arteries. Four years later, in 1925, Cotte found
that the same results could be obtained by re-
section of the superior hypogastric plexus. Cotte,
as mentioned before, called the superior hvpo-
gastric plexus the presacral nerve.

Cervicitis, the pain of labor in its first stage,
and retroumbilical (not umbilical) pain of ap-
pendicitis are visceral pains, deep seated, ill
localized, and with no somatic component.

The rupture of a corpus luteum may present
a clinical picture essentially similar to that of a
ruptured follicle except that the time of onset of
menstruation is different. Many women with
bilateral pelvic pain do not have pelvic inflam-
matory disease. Pelvic cellulitis is seen most fre-
quently in puerperal patients, and it often occurs
in nonpregnant patients after uterine or cervical
instrumentation.

Rupture of a tubo-ovarian abscess is a verv
serious condition. Often, the patient becomes
profoundly ill in a very short time before the
peritonitis develops that will cause demise. Lapa-
rotomy is done with the principal aim of estab-
lishing intraperitoneal drainage, and the intes-

tines should not be greatly disturbed. Adminis-
tration of blood, fluids, antibiotics, and so forth
should be relied on largely for the treatment.

Severe abdominal pain may arise from neo-
plasms which have undergone torsion, with
hemorrhage into the tumor which might rupture.
Late pregnancy often results in placental infarc-
tion that can simulate a placental separation.
Pains may be of intragenital origin, in which the
pelvic lesions responsible are recognizable, or
they may be extragenital, in which normal pelvic
organs are present. The cervix is rather insensi-
tive to pain, and tenacular forceps can frequently
be placed on it without too great a discomfort.

In the later years of life, many women suffer
a bearing down sensation or a “weight in the
pelvis,” which is due to a cystocele, rectocele, or
uterine prolapse. In cases of secondary pain or
dysmenorrhea, endometriosis should not be over-
looked. Endometriosis is one of the most in-
capacitating of the chronic pelvic pains. Some
of the other causes of pains that may be associ-
ated with gynecologic pathology are the extra-
genital type other than pelvic varices, relaxation
or strain over the sacroiliac joints, diverticulosis
found in the bowel, backache often due to con-
stipation, and pain caused by orthopedic prob-
lems.

Pelvic pain is a prominent symptom in many
pelvic lesions, and its interpretation requires
careful investigation. But, we should make care-
ful study of all the systems relating to the pelvis
—the gastrointestinal, the genital, urinary, neuro-
logic, and psychosomatic.

It has been stated that pain is now accepted as
a sixth and separate sense, quite apart from the
so-called primary senses of sight, hearing, taste,
smell, and touch. Visceral peritoneum is often
and is usually insensitive to local stimuli, such as
pricking, cutting, or pinching. However, anv
pull on a mesentery or attaching a viscus to the
abdominal wall will cause pain.

The nerve supply to the pelvic organs include
the bladder, perineum, vulva, vagina, and anal
regions included in the types: (a) somatic or
cerebrospinal, (b) sympathetic, and (c) para-
svmpathetic. Thus, excision of the superior hypo-
gastric ganglia or presacral nerves may relieve
primary dysmenorrhea.

Pain from the pelvic viscera reaches the
consciousness of the individual through somatic
afferent nerve fibers called the viscerosensory
nerves, which pass upward from the pelvic vic-
cera in the sympathetic chains. Some theories
set forth concerning the etiology of pelvic pain

APRIL 1958

153

Section on PAI N

have been mentioned, such as chronic metritis,
chronic salpingitis, chronic appendicitis, adhe-
sions, congestion, psychoneurosis, and ovarian
dysfunction. Under the syndrome of ovarian dys-
function, vve have pelvic pain, menorrhagia,
metrorrhagia, cystic ovaries, tender ovaries,
tender uterus, dyspareunia, infertility, and ner-
vous exhaustion.

Considerable discomfort or pain may arise from
disturbance of the functions of the bones, joints,
muscles, ligaments, and fasciae of the trunk
pelvis and lower extremities.

A clinical method of measuring the motion of
intrapelvic pain is presented by Pitkin.

Pelvic myalgia is a term coined to describe a
painful spasm of the piriformis group of muscles.
The muscles that are affected either singularly
or in groups are: (1) piriformis, (2) inferior
gemellus, (3) superior gemellus, (4) obturator
interims, (5) gluteus medius, (6) levator ani,
and (7) coccygeus. Myalgia is one of those con-
ditions causing pain, not usually found in the
pelvis, and the pain probably would not be ex-
aggerated by careful digital examination. Powell
states that about 10 per cent of these cases are
made worse by massaging the pelvis. Pelvic
myalgia is not a clinical entity, but is a compli-
cation of posterior urethritis, an anal or rectal
pathologic condition, or an orthopedic defect.

In 1921, Leriche introduced periarterial sym-
pathectomy of the internal iliac (hypogastric)
artery for the relief of pelvic pain and obtained
good results. As previously stated, in 1924, Cotte
found that by sectioning the superior hypogastric
plexus (presacral nerve of Latarjet) equally good
results were obtained as those obtained by
Leriche. In 1913, Latarjet described and named
the presacral nerve as a distinct nerve.

It is unfortunate that so many patients, and
far too many doctors, are imbued with the idea
that the only solution to many of the ailments of
women, especially chronic pain and discomfort
in the abdominopelvic region, is surgery. We
might add that women who complain of chronic
lower abdominal pain are “pushed around” medi-
cally and surgically speaking much more than
any other group of patients. Pelvic treatment
should be largely conservative unless there is a
definite indication for the removal of the organs,
such as uteri, ovaries, tubes, and so forth.

Somatic innervation applies both to the sen-
sory and the motor nerve supply to the frame of
the body. As is known, a spinal nerve arises from
a segment of the spinal cord and is composed of
an anterior (motor) root and posterior (sensory)

root. In the posterior sensory root is found the
spinal ganglion in which are located the nutrient
cells of the sensory apparatus. This ganglion will
be mentioned in connection with the so-called
sympathetic sensory nerves. After a short course
as a single nerve trunk, each spinal nerve divides
into anterior and posterior branches, which con-
tain both sensory and motor components. Thirty-
one such spinal nerves — 8 cervical, 12 thoracic,
5 lumbar, 5 sacral, and 1 coccygeal — are present
on each side of the body.

Visceral innervation is effected by the auto-
nomic or involuntary nervous system. Below the
sacral promontory, the superior hypogastric plex-
us becomes the middle hypogastric plexus, and
the latter divides at the level of the first sacral
vertebra to form the bilateral inferior hypogas-
tric plexuses.

One of the most trying problems in gynecology
is presented by the patient who relates a history
of pain for which the physician can find no satis-
factory organic cause. Minor deviations from
absolute normal, such as freely movable retro-
displacement of the uterus, cervical hypertrophy,
or a slightly enlarged ovary may be the cause of
the difficulty.

As you will remember, Menninger has pointed
out that surgery is often sought bv patients who
fear something more than they fear surgery.
Many physical symptoms find their underlying
cause in the operation of emotional disturbances
upon the autonomic nervous system. Emotional
factors may play the same role in the production
of so-called tension or migrainous headaches.
Wolff has shown that migraine headaches are
vascular in origin and develop in 3 distinct
phases :

1. The vasoconstriction phase, which is brief
and does not cause pain.

2. The vasodilation phase, which is the imme-
diate cause of pain in that pain sensation struc-
tures surrounding certain vessels are stretched
or pulled upon.

3. The edema phase, which follows the vaso-
dilation phase and lasts a considerable length of
time.

Pain is generally described as organic or func-
tional but might better be distinguished as soma-
togenic and psychogenic. In the development
of a psychosomatic disorder, there are 3 requi-
sites. (1) a psvehoneurotic predisposition, (2)
an exciting emotional conflict, and (3) restriction
of outward expression of the conflict.

It is estimated that pelvic pain accounts for
at least 35 per cent of the admissions to a

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Section on PAIN

gynecologic ward. The urologic system should
never be overlooked in differentiating obscure
pains in the pelvis or the lower abdomen, especi-
ally if they are of a chronic nature.

Mengert has given a very workable classifica-
tion of pain, the general headings of which are:

1. Pain of genital origin, such as gonorrhea,
pelvic inflammatory disease, pelvic cellulitis, and
hemorrhage.

2. Uterine prolapse, adhesions, and twisted
pedicle of ovarian cyst.

3. Periodic distention of endometrial implant.

4. Tumor incarcerated in the pelvis.

5. Rupture of uterus, tube, or bladder.

6. Pelvic neurosis.

7. Pain originating in other pelvic structures,
such as: (a) the sacroiliac, (b) urinary tract,
and (c) intestinal tract.

A retrodisplaced uterus is not considered a
cause of pelvic pain nearly as frequently as it
formerly was. There is little clinical or patho-
logic similarity between adenomvosis and the
large “chocolate cyst” of the ovary.

Some of the gynecologic diseases causing pel-
vic pain might be listed as: (1) cervicitis and
parametritis, (2) uterine enlargements, (3) pel-
vic endometriosis, (4) malpositions of the uterus,
(5) pelvic congestion, and (6) adnexa disease.
Cervicitis is manifested by erosion, hypertrophy,
eversion, cystic change, and enlargement. En-
largement of the uterus causes backache and ab-
dominal pain because of pelvic congestion from
the stretching of supportive ligaments.

Endometriosis of the pelvic viscera rates high
in the classification of gynecologic causes of pel-
vic pain. Gynecologists are becoming more aware
of this condition and are diagnosing it much
more frequently than in former years. The pres-
ence of tender, cul-de:sac nodules, a retroverted
tender uterus and fixed adnexa, lower abdominal
pain, dysmenorrhea, and dyspareunia offer strong
evidence that endometriosis is present. Howard
Taylor describes a condition that he names the
“congestion fibrosis” syndrome, in which pain is
caused by vascular and tissue congestion in the
pelvic structure.

In the treatment of pelvic pain, first, the cor-
rect diagnosis should be made if possible, and,
second, each point of pathology should be recog-
nized and treated accordingly. In endometriosis,
which causes so much pain, Greenhill and others
have suggested that testosterone be given in
doses of 25 mg. three times weeklv for four
weeks. After a rest period of three to four weeks,
this therapy is repeated.

In summary, let us say that every case of pel-
vic pain should receive a careful evaluation,
which may require two or more office examina-
tions and that no rule should be adhered to ab-
solutely. Each patient must be treated individu-
ally.

CONCLUSIONS

1. Pain brings women to their physicians more
frequently than any other cause. Pelvic pain is
responsible for the greater per cent of these visits.

2. Ovulation may be a cause of pelvic pain
more often than is diagnosed.

3. Carcinoma of the uterus or the body of the
cervix is usually asymptomatic.

4. Ruptured ectopic pregnancy is the cause of
severe pain associated with shock.

5. Thrombophlebitis may cause pain in the
pelvis or broad ligaments and should not be
overlooked.

6. Tuberculosis of the tubes should be con-
sidered in making a differential diagnosis of pel-
vic pathology.

7. The sympathetic nervous sytsem often plays
a great part in the pelvic pain of women.

8. Nerves supplying the pelvis and urinary
region include 3 tvpes: somatic or cerebrospinal,
sympathetic, and parasympathetic.

9. Myalgia is a condition not usually found in
the pelvis, which affects certain muscles.

10. “Congestion fibrosis” is a newly described
syndrome, which Howard Taylor has been work-
ing on for a number of years. He feels that it
is a cause of pain more frequently than is recog-
nized.

11. Pain caused by stones, strictures of ureters,
and urinary type infection should always be
eliminated before radical surgery is performed
in the patient whose condition has not been satis-
factorily diagnosed.

BIBLIOGRAPHY

1. Bigelow, W. A.: A study of the results obtained by section
of ovarian vessels and adjoining tissue in relief of certain
types of pelvic pain. Canadian M.A.J. 47:233, 1942.

2. Counseller, V. S.: Gynecologic symptoms of major impor-
tance to the physician in general practice. Chicago M. Soc.
Bull. 56:50, 1953.

3. Greenhill, J. P. : Relief of pelvic pain by sympathectomy
and intraspinal alcohol injections. J. Internat. Coll. Surgeons
10:218, 1947.

4. Guerriero, W. F., and Stuart, J.: Pelvic pain of gynecic or
other origin. Am. J. Ohst. & Gynec. 67:1265, 1954.

5. MacFarlane, K. T.: Pelvic pain. Canad. M.A.J. 55:267,
1946.

6. Mussey, R. D., and Wilson, R. B.: Pelvic pain. Am. J. Ohst.
& Gynec. 42:759, 1941.

7. Pitkin, H. C.: Orthopedic causes of pelvic pain. J.A.M.A.
134:853, 1947.

8. Powell, N. B.: Pelvic myalgia: complication of posterior
urethritis in males and females. J. Urol. 62:245, 1949.

APRIL 1958

155

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EDITOR’S NOTE

The paper, “Pelvic Pain in Women— a Univer-
sal Problem,” by Gilbert Douglas and associates,
which appears in this Section on Pain should be
of considerable interest to all readers, since the
condition at one time or another afflicts every
woman patient and, thus, constitutes a problem
to the physician who sees her.

Comments on this Section on Pain, criticisms,
and suggestions for papers will be most wel-
come. Physicians are especially invited to sub-
mit papers on subjects pertaining to pain for
consideration. All inquiries and manuscripts
should be sent to Dr. John S. Lundy, 102 Sec-
ond Avenue Southwest, Rochester, Minnesota,
or to the Editorial Department, The Journal-
Lancet, 84 South Tenth Street, Minneapolis,
Minnesota.

John S. Lundy, M.D.

Book Reviews on Pain

INHALATION ANALGESIA IN CHILDBIRTH, by
E. H. Seward, M.A., D.M. (Oxon.), F.F.A.R.C.S.,
D. Obst. R.C.O.G., consultant anaesthetist, High Wy-
combe Group of Hospitals; and R. Bryce-Smith, M.A.,
D.M. (Oxon.), F.F.A.R.C.S., first assistant, Nuffield
Department of Anaesthetics, University of Oxford,
1957. Springfield, Illinois: Charles C. Thomas, 58
pages. $1.50.

This small book has compressed within it much infor-
mation about the use of analgesia in childbirth. The work
is intended primarily for the instruction of midwives,
which means that the text necessarily had to be made more
explicit than would be the case in a book planned for
those with formal training in the subject. This objective
has been attained.

The chapter on nitrous oxide presents concisely a
considerable amount of historical facts and practical in-
formation about that agent. Trichloroethylene is well
covered. There are chapters on causes of failure and on
devices for administering nitrous oxide and air and also
one on apparatus for administration of trilene and air.

There is a brief index. The regulations reproduced in
appendices 1, 2, and 3 govern the use of analgesic agents
and gas-air machines by midwives as well as rules re-
stricting the practice of midwives. This book is excellent.

John S. Lundy, M.D.

HYPNOGRAPHY: A STUDY IN THE THERAPEUTIG
USE OF HYPNOTIC PAINTING, by Ainslie
Meares, MBBS., B. AGR. SC„ DPM., 1957, Spring-
field, Illinois: Charles C. Thomas, 271 pages. $7.75.

This hook describes an aspect of hypnosis that is differ-
ent.

John S. Lundy, M.D.

Current Literature on Pam

A STUDY OF HYPODERMIC NEEDLE POINTS, by

F. Franz and R. M. Tovell: Anesthesiology 17:724-

729, 1956.

“Because of the introduction of new therapeutic agents
requiring subcutaneous, intramuscular, or intravenous in-
jection, the procurement of new needles and syringes
has become a source of increasing expense to hospitals
and physicians. At Hartford Hospital, over 60,000 needles
have been procured in the last three years. During that
period, demands placed upon the purchasing agent have
increased by 50 per cent to the point where 1 needle is
required per bed approximately ever)' ten days. The
cleaning, packaging, sterilizing, and issuing of needles
to wards from central supply constitutes a major effort
that is complicated by problems of collection and re-
sharpening prior to processing for reissue. It is with the
problem of resharpening that we are concerned in this
communication ....

“The needle shapes which are satisfactory are those
combining both strength and sharpness of cutting edge.
Onlv 2 of the samples examined satisfy both these cri-
teria . . 7 . One of these is a hypodermic needle point in
its original form as received from a manufacturer ....
The other .... is the point selected for development
of a mechanical needle sharpener .... Both the
needle and the grinding wheel rotate. It is so designed
that as the needle rotates it lifts away from the wheel in
order to preserve the cutting edges of the bevel. A con-
vex bevel is produced and hooks curled backwards from
the beveled surface are ground away.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 67. Copyright by John S. Lundy.

•

FACIAL NERVE PARALYSIS AFTER GENERAL

ANESTHESIA, by j. E. Fuller and D. V. Thomas:
J.A.M.A. 162:645,' 1956.

“Attention has frequently been drawn to the danger that
exists of producing damage to peripheral nerves in the
unconscious patient by stretching or by pressure

“ Case 1. A 54-year-old woman was undergoing ehole-
cystectomy; she was moderately obese and her neck was
short. During the induction of nitrous oxide-oxygen-ether
anesthesia, upper respiratory obstruction developed . . .
This was only partly corrected by insertion of a rubber
oral airway, but it was fully relieved when the lower jaw
was lifted forward by bilateral digital pressure applied
behind the angles of the mandible .... When the
patient recovered consciousness, she was noticed to have
a weakness of the left comer of the mouth, involving
both the upper and the lower lips, and there was flac-
ciclity of the left cheek .... The disability gradually
lessened, and after three months full function had re-
turned.

“Case 2. A 53-year-old man was being operated upon
for inguinal herniorraphy; he was of heavy build and had
a thick, short neck. Early in the induction of anesthesia
with nitrous oxide, oxygen, and ether, obstruction of res-
piration at the pharyngeal level occurred. Because place-
ment of a rubber oral airway failed to relieve the condi-
tion completely, forward digital pressure was applied
behind the mandibular angles, and breathing was thereby

156

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improved .... The next day, while shaving, the pa-
tient noticed that when he opened his mouth the right
corner became pulled toward the midline .... Recov-
ery was complete in three weeks ....

“This emphasizes the need for early tracheal intuba-
tion in patients whose airway can only be maintained by
strong pressure applied to the lower jaw. These appear
to be the first such cases reported in the English-language
literature.”

From John S. Lundy and Florence A. McQuillen: Anesthesia

Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 68. Coyright by John S. Lundy.

•

VOMITING AND REGURGITATION DURING AND

AFTER ANESTHESIA. SOME CAUSES, EFFECTS,

PREVENTION AND MANAGEMENT, by John

Adriani: J. Am. A. Nurse Anesthetists 24: 231-238,
1956.

“Few happenings are as disconcerting to an anaesthe-
tist as persistent postoperative emesis .... The prob-
lem resolves itself into two phases: diat of emesis during
anaesthesia and that of emesis in the postanesthetic
period .... The majority of fatalities on the operating
table are due to asphyxia. Aspiration of vomitus, blood
and other secretions account for more than half the
asphyxial deaths .... Vomiting is an active response in
which some voluntary effort is involved. Regurgitation is
passive and involves no voluntary effort ....

“Impulses which initiate vomiting may originate in
almost any part of the body because the vomiting center
is in communication with many nerves from many areas
. . . . Many of the drugs used in anesthesia, particularly
the narcotics and the general anesthetics, may stimulate
the vomiting centers in the medulla .... Regurgitation
not only occurs without voluntary effort but even when
the vomiting center is depressed. Vomiting, on the other
hand, does not occur if the vomiting center is depressed
by anesthetics ....

“The management of the patient with a full stomach
has been a matter of debate for sometime .... When
surgery is urgent and the operation must proceed, the
best expedient is to effect a rapid induction with cyclo-
propane or Pentothal with a muscle relaxant. Intubation
of the patient using a cuffed tube is mandatory when
vomiting is anticipated . . , . Regurgitation and aspira-
tion into the trachea may occur silently and unknown to
the anesthetist ....

“Berson and the writer working at the Charity Hospital
in New Orleans introduced preoperatively into the
stomach an insoluble dye, carmine red, which becomes
soluble and red when made alkaline with ammonia. They
noted that 15 per cent of 1,000 patients studied re-
gurgitated the dye into the pharynx. In half of these,
in other words, 7 per cent, the dye was identified in the
trachea. The anesthetist was unaware of the regurgita-
tion. The factors favoring regurgitation were as follows:

( 1 ) Difficult inductions . ... (2) The presence of the
stomach tube. The incidence was greater in patients who
had Levine tubes in situ . . . . ( 3 ) Intubated patients
showed an incidence of regurgitation close to 25 per
cent ... ( 4 ) Patients who were in the head up position
aspirated more frequently than those in the supine or
head down position .... (5) The incidence of regurgi-
tation using Pentothal and nitrous oxide contrary to our
expectations was above the average of 15 per cent ....

1 he statement has been made that fluid and vomitus
cannot travel uphill. Obviously this statement is true,
but one must remember that vomitus can be sucked
uphill .... Vomiting during the recovery period is often
ascribed to anesthesia. However, many factors besides
anesthesia are involved, and anesthesia is only one of the
many causative mechanisms.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 2. Copyright by John S. Lundy.

THE GERIATRIC PATIENT AND ANESTHESIA, by

R. H. Barrett: J. Am. A. Nurse Anesthetists 24:239-
248, 1956.

“Just where does the geriatric age begin? .... Maybe
we should be guided by the old adage that ‘one is as
old or as young as one feels’ .... Anyone who is engaged
in the administration of anesthesia is engaged in a
dangerous profession. Every time you anesthetize a pa-
tient, the choice of life or death rests squarely in your
hands, and it makes no difference whether you are a
physician or a nurse. For this reason, it behooves all
of us to know something about the people we are put-
ting to sleep ....

"We are always dealing with an individual in the
practice of medicine .... See your patient pre-
operatively—before he has had pre-anesthetic medication,
preferably the day before surgery. If for no other reason
than from the purely humanitarian standpoint, I urge
that this visit be made by the anesthesia nurse as well
as the anesthesiologist . . . .Tell the patient what he
can expect— both before and after anesthesia and surgery
. . . . Tell the patient what you are going to give him
for anesthesia and approximately how you are going to
give it. At least, tell him what the initial part of your
procedure will be. If you have a post-anesthesia room
or recovery room in your hospital, be sure to tell your
patient that this is where he will be after surgery, so
that when he awakens, he will not think he is in the
wrong place . . . Ask the patient about his previous
anesthesia experience ....

“Having convinced— or attempted to convince— this
individual that he has a better chance of living during
anesthesia and surgery today than he has while crossing
the street in front of the hospital after his convalescence,
you proceed to order premedication, or, at least, check
what others may have ordered for you. With the ever
increasing popularity in the use of light anesthesia, for
even the most major of surgical procedures, adequate
premedication is more important than ever .... If
someone else has ordered the premedication on the case
you are going to do, be sure it is what you want for
the patient you are going to anesthetize. You are a
registered nurse, specially trained in anesthesia tech-
nology. You are about to embark on a life or death
procedure, and it is expected that you will put to use
all of the acumen that you have collected over the past
several years of your life. If you do not agree with the
premedication, or even the type of anesthesia that has
been ordered by someone else, find out why it was
ordered. It may be the best for the patient, but, be sure
you know why. You are morally, if not legally, respon-
sible for every patient you anesthetize ....

“If you work with an anesthesiologist, your problems

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157

Section on PAIN

are reduced a hundredfold. If you do not work with an
anesthesiologist, naturally, you will not emulate your
surgeon on internist, but, you do have a right to know
‘whys and why-nots’ of what you are trying to do ... .

“The anesthetic technique, which, in our hands, for
the past several years, has proved to be the safest for
aged and debilitated patients is a combination of nitrous-
oxygen and a muscle relaxant ....

“Our technique is to start first an infusion of 5 per
cent glucose in quarter strength saline solution in the
adequately premedicated patient. We do not use scopola-
mine even in the very aged. Nitrous oxide and oxygen,
in an 80-20 mixture, is administered for a few minutes
by face mask. It is important to use non-rebreathing
technique especially during the induction period, in
order that bodily nitrogen will be replaced by nitrous
oxide. Because nitrous oxide is a relatively mild analgesic,
it is necessary to attain optimum concentration. The non-
rebreathing technique also prevents build-up of carbon
dioxide. After the patient is asleep, 20 to 40 mg. of
succinylcholine are given intravenously through the in-
travenous tubing, and the posterior pharynx and larynx
are sprayed with a topical anesthetic solution. This
spraying can be done before induction, but the comfort
of the patient is not disturbed by delaying it until the
patient is asleep. For that very short period while the
muscle relaxant and the topical anesthetic are produc-
ing their optimum effects, administration of nitrous-
oxide and oxygen is resumed bv face mask. A cuffed
endotracheal tube is then inserted, under direct vision,
and the patient is carried on hand-assisted respiration
throughout most of the surgical procedure ....

“Routine blood pressure, pulse, and often electrocardi-
ographic tracings are followed. Intravenous fluids, in-
cluding blood, are given as needed. On completion of
surgery, the patient is allowed to awaken gradually ....
The practice of geriatric anesthesia today in any general
surgical hospital is the practice of clinical anesthesia
per se; and the practice of anesthesia itself, as a specialty,
is and always has been not the specialized knowledge of
what to do now, but rather, the acumen gained by study
and experience which qualifies one to know what to do
next.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 14. Copyright by John S. Lundy'.

BASAL HYPNOSIS BY THE RECTAL ADMINISTRA-
TION OF A MULTIDOSE THIOBARBITURATE
SUPPOSITORY (Preliminary report), by S. N. Al-
bert, H. N. Eccleston, Jr., J. S. Boling, and C. A.
Albert. Anesth. & Analg. 35:330-336, 1956.

“The rectal administration of sodium Pentothal and
sodium Surital in 10 per cent solution has gained some
popularity as a rapid acting basal hypnotic in adults
and children. The difficulties one encounters when ad-
ministering rectal solutions has greatly limited the daily
use of this technique .... Sodium Nembutal supposi-
tories are sometimes used for this purpose. The onset
of action is slow and quite frequently the patient is
agitated and difficult to control ....

“It was desirable therefore to develop a simple and
practical method whereby rapid-acting sodium thiobar-
biturates could be administered rectally from stock

preparations in tailored doses for each individual patient
with minimal discomfort. Sodium Pentothal or sodium
Surital were incorporated in a suppository, cylindrical in
shape and of uniform diameter and consistency. Each seg-
ment of the suppository contains a fixed amount of active
ingredients, and the total amount to be administered de-
pends on the length of the suppository used. The sup-
positories are inserted into the rectal pouch stimulating
the procedure of taking a rectal temperature ....

“Multidose suppositories containing sodium Pentothal
were administered to 85 patients. Sodium Surital sup-
positories were administered to 65 patients. The results
in both series were similar in effect and duration, so we
incorporated both series into one total of 150 unselected
cases with ages ranging from one month to 99 years ....

“Rapid and accurate dosage determination for each
patient is feasible without elaborate preparations. The
onset of hypnosis is rapid, occurring within 5-10 minutes.
Induction of anesthesia is smooth. There was no apparent
depression of respiration, change in the blood pressure
and the pulse rate after the administration of the sup-
positories. One may conceive a combination of slow and
rapid-acting barbiturates incorporated into a multidose
suppository in order to give a rapid induction and pro-
longed hypnosis utilizing tailored doses to fit the need
of each patient.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 5. Copyright by John S. Lundy.

•

PUDENDAL BLOCK: TWO NEW TECHNIQUES,

by Virginia Apgar: Anesth. & Analg. 36:77-78, 1957.

“In 1951, the technic of pudendal block was examined
critically with the hope of improving its success. In order
to perform a satisfactory block, it was necessary to
palpate the ischial spine transvaginally on each side. It
seemed a simple matter to direct a needle between the
first and second fingers to this site, and to redirect it
medially, to a point just inferior to the tip of the spine,
then to insert it to a depth of 1 cm. and inject the
anesthetic solution after aspiration to rule out intravas-
cular placement ....

“A second route for pudendal block has proved useful
for certain gynecologic procedures and in males under-
going eystometric examinations. The posterior approach
was suggested by observing the perineal anesthesia which
was obtained during posterior femoral cutaneous nerve
block performed by Lundy. The patient is placed in
the Sims’ position, and the upper leg is sharply flexed.
A line is drawn between the posterior spine and the tip
of the greater trochanter. This line is bisected by a per-
pendicular line, a technic similar to that used in sciatic
nerve block. About 6 to 7 cm. downward on the per-
pendicular line, a needle is inserted and advanced in a
slightly outward direction until bone is met. This bone
is the posterior surface of the ischial spine on which lies
the pudendal nerve .... This approach has been con-
sidered too hazardous for obstetrical use, because of the
proximity of the infant’s head. Aspiration to identify the
pudendal artery and vein is performed before injection
of the anesthetic solution.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 9. Copyright by John S. Lundy.

158

THE JOURNAL-LANCET

1

Journal

I A III ■**' I SERVING THE MEDICAL PROFESSION OF MINNESOTA.

V W'W V NORTH DAKOTA. SOUTH DAKOTA AND MONTANA

Not by Bread Alone

WILLIAM S. MIDDLETON, M.D.
Washington, D. C.

In assuming this yoke, I wish to make it clear
that this is a medium of conduction and of
communication and not a measure of personal
subjugation.

To come to you today is indeed a privilege,
and I would take the prerogative, indeed, with-
out compunction, of changing the trend of your
thought, if possible, to the past and not to pro-
ject it into the future as has been done in the
past two days. It is significant that the begin-
nings of the modern therapy of tuberculosis had
rather insecure foundations. We are all familiar
with Thomas Sydenham’s preachments of horse-
hack riding and exercise in general in the seven-
teenth century, which were the prescription not
only bv choice but of necessity. The very begin-
ning of modem therapy of tuberculosis may be
traced to George Bodington s suggestion in 1840
that the tuberculous patient be sent to hospitals
built in the country. In his treatment of pulmon-
ary consumption, he therefore felt that there was
the necessity for an environment different from
that of the urban hospitals. To George Boding-
ton goes the chief credit for the initiation of the
sanatorium movement. This found direct expres-
sion in the suggestions and the activity of Her-
man Brehmer at Gorbersdorf in 1859, when the
rural sanatorium was begun in Germany and
physical exercise was continued at varying levels.

william s. middleton is chief medical director of
Veterans Administration, Washington, D.C.

This article is reprinted with permission of the
author from Transactions of the Sixteenth Confer-
ence on the Chemotherapi/ of Tuberculosis, Febrti-
ary 11 to 14, 1957, St. Louis, Missouri.

Indeed, the exercise was extended to such a de-
gree that his student, Peter Dettweiler, differing
from the master, started his own sanatorium at
Falkenstein in 1875. Dettweiler really set the
pace for the more modem conception of sanator-
ium treatment. Of course, there is the work of
Carl Spangler at Davos in Switzerland, again in
the same vein, and then in our own country,
there is the work of Edward Livingston Trudeau
at Saranac that so greatly influenced the move-
ment for the treatment of the tuberculous patient.
The “Little Red” sanatorium was the beginning,
and a great influence on medical thought and ac-
tion in this country stemmed from the movement
initiated by Trudeau. His immediate pupils and
his co-workers, Lawrason Brown and Edward
Baldwin, are familiar to all of you.

The tradition of Trudeau has been carried
down in the generations intervening from 1885,
w hen he commenced his sanatorium, which was
a true movement for the modernization of
treatment as it was recognized at the time. In
general, all this period is B. K., that is to say,
Before Koch. In that particular direction, we
have living examples. I would single out Dr. J.
Burns Amberson, except for the fact that in the
December number of the Review, I understand
from a very eminent authority, James Waring,
that he has taken to making mousetraps. In any
event, this movement, which carried over into
the present era, had begun before Koch. When
Koch made his observations on the discoverv of
the tubercle bacillus in 1882, he attempted to
apply that information to treatment. The story
of old tuberculin is familiar to all of you. With-

out denying to Robert Koch his tremendous con-
tribution, it became obvious early that old tuber-
culin was not to be an essential element in the
treatment of tuberculosis.

Then came the intervention of surgery. For
the beginnings of thoracic surgery, Carlos For-
lanini introduced the pneumothorax in 1892 or
1895. The date depends on whether Garrison or
Long is considered the authority. Succeeding
him and supplementing him independently, John
B. Murphy popidarized the method in this coun-
try in 1895 or 1898, depending again on whether
Garrison or Long is your authority. In my stu-
dent days, more radical measures of therapy in-
cluded Schede’s very active work and, later, the
catalyzing effect of World War I was felt. It so
happened that as the medical man on a chest
surgical team in World War I, I was thrown into
close contact with thoracic surgeons. Under Ma-
jor, later Lt. Col., John L. Yates, I had the op-
portunity to meet men who were making history
in this area of surgery: namely Gask, the Eng-
lishman; Lockwood, the Canadian; and Tuffier,
the Frenchman. These surgeons were working
under terrific handicaps, because the support of
anesthesia was not always secure and none of the
antimicrobial agents was yet available. Lilien-
thal, another American, did notable work in that
period. Sauerbruch, a German, often denying
contact with the outside world, was a notable
contributor. I woidd like to pay tribute to a
giant among them all — John Alexander — who,
in my judgment, in the post-World War I period,
gave the greatest impetus to surgery of the lung
in this country. He influenced more individuals
than any other surgeon in this field. John Alex-
ander and Ewarts Graham were the great leaders
of the movement in this country.

The period of which we are speaking is, of
course, the period B. C., that is to say, Before
Chcmothcrapij, or I might, if I had been a little
bit more prompted in taking poetic license, have
said B. W., Before Waksman. This innovation
has initiated an entirely new viewpoint in our
treatment of tuberculosis, not only from the
medical but also from the surgical standpoint.
Those of you who have gone through the pre-
antibiotic, preantituberculosis drug or B. C. pe-
riod have a clear appreciation of the advantage
that has been given us by streptomycin, para-
aminosalicylic acid, isoniazid, cycloserine, Pvra-
zinamide, and the other agents used in this par-
ticular direction. Without them, the surgery of
tuberculosis would revert to the immediate post-
World War I period. We have the great ad-
vantages of anesthesia and of the antimicrobial
agents.

From our present vantage point, it is impor-
tant to view the past as well as the future. The
battle is not won, and we cannot rest on our
oars in the assumption that things will go for-
ward at the accelerated rate of the recent past.
Are we losing some of the advantages of the B.C.
period? By dependence upon phvsical and
chemical agents, are we losing some of the ad-
vantages that the patients had at an earlier
stage? I think the answer to both these ques-
tions is in the affirmative. It behooves us to look
carefully to ourselves to determine in what
measure these advantages may be regained. In
the first place, it is accepted as an axiom that
there is no tuberculosis except from a tuber-
culous subject. There must be a source and then
a susceptible host. It is important in this concept
that we view the subject realistically. The ideal
of tuberculosis control is admittedly prevention.
Are we as carefully screening our populations
as we did B.C.? Are we as carefully educating
the public and the profession as we did? Whether
we wish to admit it or not, the great advance in
the preantituberculosis drug period, B. C., was in
the education of the laitv, to which the profes-
sion reacted rather slowly. In this educational
movement, we must not relax one iota as we
look to the future. In the next place, it is appar-
ent that the early recognition or case-finding
of tuberculosis is a vital issue. Even if we have
given every consideration to preventive meas-
sures, including use of BCG in its place, instances
of tuberculosis will continue to occur until the
sources are wiped out— the millenium of pre-
vention. Early recognition by proper screening
methods is familiar to all of you; we must never
neglect them. Thev may appear less spectacular
and more humble, if you please. Nevertheless,
they are the keystone to the ultimate control of
this disease, and then, in turn, follows the pro-
per application of treatment. We will not denv
for a moment that under sanatorium manage-
ment of rest, adequately balanced nutrition, and
fresh air, there were certain advantages. Do not
lose them simply because we have other more
readv measures, which may actually be short
cuts. In the last analysis, there is still an advan-
tage to be gained by sanatorium management.

We realize that in this program of earlv tuber-
culosis control, there is the necessitv for a close
rapport with the patient. This represents first
a matter of the education of the patient, his
family, and the community. No longer is the tu-
berculous patient a pariah in society. We have
definitely gained that vantage point. Further-
more, the long term of this illness has been a
challenge which has been met by educational

160

THE JOURNAL-LANCET

methods from the beginning. In the conquest of
the disease, the patient must conquer himself be-
fore he starts to conquer his illness. The family
educated to the point of accepting its particular
responsibility, the community accepting its place,
and the patient educated to the limits of his
capacity to accept information constitute a team
of resistance. This is the keynote to the proper
rapport between the patient and the physician.
The physician must realize the psychology of the
ill and appreciate that they are peculiarly ego-
centric. In spite of the traditional spes phthisica,
we know that each patient will have to be
trained to meet the situation with which he is
confronted. Unless there is an intimacy of con-
tact between physician and patient, we will not
have gained our primary objective of the cooper-
ative therapeutics so necessary for complete care.

There are a number of points of obvious weak-
ness in our present pattern. We may take first
the debit side of the sheet for the physician. It
must be realized that the patient is distressed
when he finds the physician more interested in
the etiology than in the host of the disease. He is
immediately disturbed when the physician, too
technical to come into grips with his patient’s
problems, loses contact in his abstraction. It is
perfectly true that we wish to advance scientifi-
cally; but the meticulous details of the labora-
tory must not come between the physician and
this human subject of disease. “For this is the
great error of our day in the treatment of the
human bodv, that physicians separate the soul
from the body.” That is not a personal state-
ment but a quotation from Plato. The day is
somewhat removed; but, the fact remains that
we cannot afford to permit any barriers to come
between us and the patient. This patient-physi-
cian relationship is never more intimate than in
the care of the tuberculous individual. We turn
to the credit side of the column. Let there be
good cheer in the contact with the patients. May
we never bring gloom to the sick room. Further-
more, the appreciation of the necessity for in-
terest in the patient’s welfare by the utilization
of every agency is imperative. We in the Veter-
ans Administration are not working in a vacuum
in this particular subject and field. We have the
support of the psychiatrists, clinical psycholo-
gists, and the great help of the supporting cast
in physical therapy, occupational therapy, nurs-
ing, special services, and social service. We have
the library, and we have the clergy. Do not
minimize anv one of these elements, because this

patient entrusted to our care is one who is de-
tached from his place in societv. Unless we
attempt to fill that void, we may, in truth, be
working in a vacuum. We turn to the institution
itself. There is a verv definite personality in
hospitals. Let yours be a warm, cheerful atmos-
phere rather than a cold, impersonal type.

It is perfectly true that we all have problems.
Whether in the Army, Navy, Air Force, United
States Public Health Service, civilian institutions,
or the Veterans Administration, the problem of
the irregular discharge presents itself. Every
irregular discharge is a discredit to the manner in
which the patient has been treated. Do not mis-
understand me. I do not think that all problems
are soluble. There are many of these problems
that have grown over the years; but they are on
the debit side of the ledger because, first, ade-
quate therapy has not been provided for that
given individual. In the second place, he has
been returned, a potential source of infection, to
home and society without arrest or adequate
treatment of his condition. I am greatly dis-
tressed when I go into our institutions and find
that there is a patient, or patients, who refuse
to undergo surgery. That does not mean that the
staff is always at fault; but it occurs to me that
there is a breakdown in the fine chain of com-
munication between medicine and surgery and
the patient. In each instance where morale is in
question, where there is a barrier between pa-
tient and physician, we should look first to our-
selves for the source and the answer. It is per-
fectly correct to turn our clinical psychologists
and psychiatrists loose on this group of patients.
They have given us a great deal of information
and assistance in this area. In this breach, there
must be an answer, and we should attempt to
ascertain it. Certainly, as we grow larger, as our
institutions become more and more involved, an
atmosphere of impersonality may prevail. If this
be the case, there is always the difficulty, first
for the patient, then for the family, then for the
community, to make their necessary contribu-
tions to what I have termed cooperative thera-
peutics. It behooves us, then, to take to heart
the facts that we have made great gains in medi-
cine and surgery and that the advantages of these
advances to the individual suffering from tuber-
culosis are stupendous. However, so that we
may not compromise this advantage, we should
look to the various supporting elements and re-
member that we cannot depend on the medicine
and surgery alone to effect the cure.

MAY 1958

161

The Development of Tuberculosis in a
Controlled Institutional Environment

ABRAHAM GELPERIN, M.D., Dr. P.H.

Chicago, Illinois

Present programs of tuberculosis prevention
in controlled institutional environments con-
sist primarily of screening and diagnostic pro-
cedures. Admission and periodic chest x-ray
films, initial tuberculin tests with regular repeat
testing of negative reactors, as well as bacterio-
logic examinations in suspected cases, are the
accepted routine. Within recent vears, chemo-
prophylaxis of children who are recent converters
is a growing adjunct.1 Some directors of pro-
grams are even giving adults the benefits of the
latter routine.2 The slowly declining morbidity
of tuberculosis in this country3 and the redirec-
tion of programming in some communities4'5 will
perforce result in a continuously lowering tuber-
culosis disease potential for all institutions.

It was considered that an evaluation of such
institutional programs would indicate to some
degree the effectiveness and usefulness of the
various facets of a control program. Two in-
stitutions were studied. One is a 5,000-bed facil-
ity for the care of the mentally retarded, the
Dixon State School, Dixon, Illinois. The other
is the 516-bed Veterans Administration Research
Hospital, Chicago, Illinois. The former is a part
of the State Welfare Department, and the latter
is a university affiliated general hospital. They
will be considered separately, since they are dis-
similar in patient populations and with some-
what different control programs.

DIXON STATE SCHOOL

Dixon State School draws its residents, as the
patients are called, from Cook Countv and the
counties to the West and Northwest. It is like
a town in some respects. The residents live in
one-story dormitory cottages. There is a general,
communicable disease, and tuberculosis hospital,
as well as facilities for education, recreation, and
rehabilitation.

abraham gelperin, former assistant superintendent
of the Dixon State School, Dixon, Illinois, is on the
staff of the Veterans Administration Research Hos-
pital, Chicago, Illinois.

Prior to 1952, there had been sporadic tuber-
culin surveys, the first occurring in 1943. Annual
chest x-ray films were instituted in 1947. In
1952, both 70 mm. films and tuberculin testing
which utilized the intracutaneous injection of a
1 to 1000 dilution of Illinois State Health De-
partment old tuberculin were instituted for all
residents on a semiannual basis. Of importance
is the fact that the key personnel involved have
remained. Information concerning the newly
diagnosed cases of tuberculosis for the period
1952 through 1956 and of all cases of active
disease for the previous five years was obtained.
In addition, the results of tuberculin tests on new
admissions during the 1952-1956 period were
studied.

During 1947 through 1951, a total of 115 in-
dividuals were diagnosed as having active tuber-
culosis. Of this number, 64.4 per cent were males,
some 8 per cent above the average male census.
Of the 112 total with pulmonary infections, 44
or 39.2 per cent had minimal disease, 50 or 44.6
per cent had moderately advanced, and 18 or
16.7 per cent had far advanced tuberculosis.

For the period 1952 through 1956, when an in-
tensified case finding program was instituted, a
total of 65 new cases of tuberculosis were found,
primarily through the x-ray program. In addi-
tion, 18 individuals had relapses of previouslv
“stable” disease. The seeming paradox is that
fewer cases were found during a period of more
intense search. The percentage of males re-
mained constant— 64 per cent of 80 patients with
pulmonary disease were men— 57.5 per cent had
minimal infection, 32.5 per cent had moderately
advanced, and only 10 per cent had far advanced
disease. There was, however, an 18 per cent in-
crease in diagnosed minimal cases.

Table 1 emphasizes the difficulty of making a
definite diagnosis of active tuberculosis even in
an institutional population. The time lag is a
serious handicap for control programs, especially
in the free-living population.4 Within this group
of 65 cases, there were 7 deaths. Three were
caused bv tuberculosis, 1 had an initial diagnosis

162

THE JOURNAL-LANCET

TABLE 1

MONTHS TO DIAGNOSIS OF 65 CASES NEWLY DIAGNOSED
DURING 1952-1956, BY DIAGNOSTIC CATEGORY

Months to
Diagnosis

Minimal

Moderately

Advanced

Far

Advanced Other Total

0 to 2

15

11

4

2

32

3 to 5

14

6

0

i

21

6 to 8

8

1

0

0

9

9 to 11

1

1

1

0

3

Total

38

19

5

3

65

TABLE 2

LENGTH OF STAY IN INSTITUTION PRIOR
TO DEVELOPMENT OF TUBERCULOSIS
1952-1956

Number of Number of

Years Patients

<1

3

1 to 2

0

2 to 3

0

3 to 5

3

5 to 10

16

10 to 15

22

15 to 20

8

20 to 30

12

30+

1

Total

65

of far advanced disease, and 2 were diagnosed as
having minimal infection. Rapidly progressive
disease developed in the latter in the face of
maximum therapy.

The tuberculin history of the 65 individuals
revealed that all were tuberculin positive at
time of diagnosis. However, further evaluation
showed that 19 had come to the institution with
negative skin reactivity. Four persons had tuber-
culin conversions during the one year prior to
development of active disease, 1 case converted
within the previous two years, and 2 individuals
converted during the previous three years. Of
the total, tuberculosis developed in the majority
some years after admission, as shown in table 2.
Two of the 3 patients who were reported to have
active disease within the first year revealed active
tuberculosis at time of admission.

The 1,472 admissions for the period 1952
through 1956 were studied. Of this number, 951
came from Cook County and 521 from the other
counties. Since the population characteristics
in Cook County are significantly different from
the rest of the population area, all data were
separated. Of the total admissions, 529 were not

residents of the Dixon State School as of January
1, 1957, because of death or absolute or condi-
tional discharge from the institution and were ex-
cluded from the study of this group. Sixty-one
per cent were under age 10, and 21 per cent were
age 20 and over. It was considered that the
status of the tuberculin reaction played no part
at all in their permanent or temporary absence.
Thus, the remaining 943 were evaluated.

Table 3 presents, in condensed form, a sum-
marization of the raw data. There was the ex-
pected sharp rise in the ratio of positive reactors
with increase in age. The total number of per-
sons with initial positive tests is small, reflecting
the preponderance of children in the new ad-
missions studied during this five-year period.

There were 56 tuberculin conversions in the
804 individuals with initially negative skin tests.
Table 4 shows the period of communal contact
prior to the tuberculin conversion. It was noted
that there was no particular living, educational,
recreational, or rehabilitation area that produced
any unusual number of converters. Except for 7
instances in the Cook County group, all con-
verters were over 15 years of age. None re-
ceived chemoprophylaxis. Clinical and x-ray
evidence of active tuberculosis had developed in
2 adults, 2 out of 33 tuberculin conversions in
age group over 20.

The tuberculosis control program for employ-
ees entails an initial tuberculin test with no re-
testing of negative reactors. There are routine
pre-employment chest x-ray films, which are
followed by a minimum of semiannual chest
x-ray films for all employees. During 1952
through 1956, active disease developed in 2 em-
ployees who had been working for some years.
Roth were considered to have had evidence of
“healed” tuberculosis infection. An even more
important service has been the uncovering of
suspected disease in a number of applicants and
their referral to appropriate health agencies.

VETERANS ADMINISTRATION RESEARCH HOSPITAL

The Veterans Administration facility, on the
other hand, is a general hospital treating adults
only. It is located in the major source population
area of the Dixon State School. The hospital
routine consists of a chest x-rav film only on
patients as they are admitted or as soon after-
ward as possible. There is the well-known chest
x-ray film program for all employees and, in
addition, a tuberculin testing program consist-
ing of an initial test with periodic retesting of
negative reactors. Prior to July 1956, the 2-
strength PPD technic was utilized. Subsequent
to the above date, a single test with intermediate

MAY 1958

163

TABLE 3

INITIAL TUBERCULIN TESTS AND CONVERSIONS BY SOURCE POPULATION, AGE GROUP, AND SEX

Age

groups

Initial

tests

Male

Conversions

Female

Initial

tests Conversions

Initial

tests

Total

Conversions

+

5

10

15

Cook

0- 9 -

196

0

125

3

-321

3

Countv

-f

14

7

21

10-19 -

65

10

66

4

131

14

+

32

23

55

20+ -

25

5

39

10

64

15

-f-

2

0

2

Other

0- 9 -

94

0

61

0

155

0

counties

+

11

2

13

10-19 -

53

3

45

3

98

6

+

22

11

33

20+ -

26

9

9

9

35

18

+

7

10

17)

County

0- 9 -

290

0

186

3

476)

52%

3

totals

+

25

9

34)

10-19 -

118

13

111

7

229)

ZO /c

20

+

54

34

88)

20%

20+ -

51

14

48

19

99)

33

TABLE 4

DURATION OF INSTITUTIONAL STAY PRIOR TO TUBERCULIN CONVERSION

Months

Sex

0-5

6-11

12-23

24-35

36+

Total

Cook

M

0

2

5

6

2

15

county

F

2

3

5

5

2

17

Other

M

i

2

5

2

2

12

counties

F

0

2

3

2

5

12

Total

3

9

18

15

11

56

TABLE 5

CLASSIFICATION OF EMPLOYEES ACCORDING TO EXPOSURE,

GROUP, OCCUPATION,

AND SEX IN V.A.

RESEARCH HOSPITAL

OCTOBER 1, 1956

Tuberculin

test

Total

Positive

Negative

Not

tested

Persons

Male

Female

Male Female

Male

Female

Grand total

752

288

219

83

139

19

4

Group A

28

14

10

3

1

0

0

Group B

724

274

209

80

138

19

4

Physicians

66

28

2

15

0

19

2

Nurses

117

1

60

0

56

0

0

Attendants

112

66

33

15

8

0

0

Laboratory personnel

48

17

9

10

12

0

0

Other

371

162

105

40

62

0

2

164

THE JOURNAL-LANCET

TABLE 6

PERSONNEL HAVING NEGATIVE TUBERCULIN TESTS ACCORDING TO
AGE, OCCUPATION, AND RACE IN V.A. RESEARCH HOSPITAL, OCTOBER, 1956

Total t White a r Non-white ■n

persons Total <30 yr. 30-49 yr. .51)*- yr. Total 30 yr. 30-49 yr. 50+ yr.

Grand total

222

154

81

Group A

4

2

1

Group B

218

152

80

Physicians

15

15

7

Nurses

56

56

44

Attendants

23

2

0

Laboratory personnel

22

18

10

Others

102

61

19

strength had been employed. A summary of the
tuberculin status of all employees as of October
1, 1956, is presented in tables 5 and 6. Group A
was comprised of those who had practically no
contact with patients and was quite small in
number at that time, only 28 of 752.

The information obtained on the entire group,
which was composed of all types of general
hospital personnel who had been present for
varying lengths of time since the hospital opened
in November 1953, does not mirror the effect
of the institution upon them. However, a sum-
mation of the results of tuberculin testing of
new employees and retesting at three-month
intervals for all within group B and at six-month
intervals for group A, in a hospital that does not
admit known cases of tuberculosis except in an
occasional temporary emergency, suggests that
the tuberculin conversions, as shown in table
7, are a function of the endemic area in which
the hospital is located. Of the 2 professional
groups most closely associated with patients, a
tuberculin conversion developed in only 3 of
the 80 nurses and 2 of the 13 doctors retested
within the year, October 1, 1956, to October 1,
1957. Of the 51 employees in the group with
minimal contact with patients, 7 showed tuber-
culin conversion, and 15 of the remaining 142
employees in group B also presented evidence
of a new subclinical tuberculous infection.

DISCUSSION

The basic question that arises concerns the func-
tion and puqiose of the tuberculin test. In cases
of pulmonary or other systemic diseases in which
tuberculosis is a differential diagnosis, the tuber-
culin test is a highly specific diagnostic pro-
cedure.6 However, the testing of either employ-
ees or resident patients in an institution and
faithful recording of the results does not in it-

57 16

68

39

25

4

1 0

2

2

0

0

56 16

66

37

25

4

8 0

0

0

0

0

12 0

0

0

0

0

1 1

21

11

10

0

7 1

4

4

0

0

28 14

41

22

15

4

TABLE 7

SUMMATION OF ONE

YEAR’S

TUBERCULIN

RETESTING, BY

EXPOSURE

GROUP

AND OCCUPATION

Exposure group

and

Tuberculin reaction

occupation

T otal

Positive

Negative

Group total

286

27

259

Group A

51

7

44

Group B

235

20

215

Physicians

13

2

11

Nurses

80

3

77

Attendents

40

5

35

Laboratory personnel

22

2

20

Others

80

8

72

self add anything to the control of tuberculosis.
Why do a tuberculin test?— tradition or more
information? How is it to be used? In children,
a recent tuberculin conversion may result in
chemoprophylaxis as well as the usual investiga-
tion of intimate contacts to possibly uncover the
source of the new tuberculous infection.

The report of the cooperative study of some
2,700 children under the sponsorship of the
United States Public Health Service was en-
couraging. These recent converters were separ-
ated into two groups; one received chemopro-
phylaxis and the other a placebo. There was a
significant reduction in the incidence of evident
tuberculous disease in the treated group. Coidd
not the same be done with adults? Certainly,
they are not less important. In reality, do we
know now, with the changed clinical character-
istics of tuberculosis as well as ecology, the
chances of active disease developing in a free-
living or institutionalized adult within either
months or years after the first invasion by the
tubercle bacillus? Would the effect of chemo-
prophylaxis be similar to that observed in child-
ren? The long-term effectiveness of any tuber-

MAY 1958

165

culosis control program must be an integral part
of planning. Tuberculosis constantly reminds us
that it frequently lives as long as its host.

The observations presented suggest that the
disease in the institution, as in the free-living
community, develops primarily in those who
have had contact with tubercle bacilli years
before they entered the institution or came to
our attention. The problem of tuberculin con-
version was significant in the adult group in the
Dixon State School, reflecting institutional in-
fections in spite of an intensive control program.
The part that sublinical infection plays in indi-
viduals without roentgenograph ic evidence of
active disease is a moot point.

Patients or residents in an environment such
as the Dixon State School are in much more in-
tense social contact with their peers than in anv
free-living community. The finding, during 1952
through 1956, of a fewer number of individuals
with tuberculosis than diagnosed prior to the
intensified campaign emphasizes the question
of subclinical dissemination, the real contribution
made by the yearly x-rays of all residents for the
period 1947 through 1951, and the reasons for
doing and ignoring the tuberculin test. The
Veterans Administration Research Hospital ex-
perience is considered to be primarily a reflection
of the tuberculosis endemic in the external com-
munity. A tuberculin testing program in an in-

stitution does the same for the institution. In
the latter instance, however, the opportunity is
at hand for doing something about the offending
community.

SUGGESTIONS

1. Utilize intermediate strength PPD or its
equivalent for all tuberculin surveys in order to
facilitate comparability of studies.

2. Initiate a cooperative study for adults simi-
lar to that just reported for children.

3. Institutions might attempt to segregate their
present patients or residents with negative tuber-
culin reactions and allocate tuberculin negative
new admissions and ward or cottage personnel
to such units.

4. An intensive study of institutionalized adults
might clarify a few of the reasons why only some
individuals suffer clinical relapse.

5. A considerable number of adults in whom
clinically evident tuberculosis does not develop
probably have periods of subclinical infectious-
ness, and the frequency parallels the present sex
and age specific morbidities.

6. The chemotherapy of abeyant tuberculosis
may be as rational as the specific treatment of
latent syphilis.

7. The incidence of active tuberculous disease
in recent adult tuberculin converters is also sig-
nificant, especially in institutions.

REFERENCES

1. Mount, F. W.: Prophylactic effects of isoniazed on primary
tuberculosis in children: preliminary report. Am. Acad. Pediat.
meeting, October 8, 1957.

2. Galinsky, L. J.: Personal communication.

3. Feldman, F. M.: How much control of tuberculosis: 1937-
1957-1977? Am. J. Public Health 47:1237, 1957.

4. Gelperin, A., Galinsky, L. J., and Iskrant, A. P.: Appraisal
of tuberculosis case finding. Pub. Health Rep. 70:761, 1955.

5. Gelperin, A.: Abeyant tuberculosis. Dis. Chest, in press.

6. Furculow, M.: On usefulness of tuberculin skin test. Am. J.
Public Health 46:1064, 1956.

Bacteremia caused bv gram-negative bacilli occurs fairly often in patients
with diabetes mellitus. Fasting blood sugar determinations for patients with
such bacteremia and blood cultures for diabetic patients with unexplained fever
are recommended.

The urinary tract is usually implicated as the source of infection, so that
prophylactic antibiotic therapy is advisable if any operative procedure or
manipulation of the urinary tract is contemplated. Vigorous antibiotic treat-
ment is mandatory if urinary infection exists. A combination of a streptomycin
compound and one of the tetracycline group of antibiotics is recommended for
treatment of gram-negative infections.

Of 137 patients treated for gram-negative bacteremia, 14 also had diabetes
mellitus. The coli-aerogenes group of organisms was responsible for the infec-
tion in 12 of the 14 diabetic patients, and the urinary tract was thought to be
the source for invasion of the blood stream in all but 1 patient.

William J. Martin, M.D., John A. Spittel, Jr., M.D., William M. McConahey, M.D.. and
Warren A. Bennett, M.D., Mayo Clinic, Rochester, Arch. Int. Med. 100:214-220, 1957.

166

THE JOURNAL-LANCET

Children of America Need Our Help

J. ARTHUR MYERS, M.D.

Minneapolis, Minnesota

THE AMERICAN SCHOOL HEALTH ASSOCIATION

with more than 6,000 members operates in a
most fruitful health field from the standpoint of
America’s most important asset— the good health
of its people.

In this country in 1954, there were 16,000,000
preschool children, 27,118,000 from 5 to 14 years
old, and 12,854,000 from 15 to 19. In our schools,
there are 1,000,000 professional and 200,000 non-
professional workers. Thus, the children and
school personnel members numbered 57,172,000
—approximately one-third of the nation’s popu-
lation.

Human minds are never so impressionable and
so retentive as during the period of childhood.
It is a common observation that throughout life
people have clearer and better memories of their
childhood experiences than of those which occur
subsequently.

just now I am enjoying some of my most
pleasant experiences to date from work done for
children, which emphasizes their retentive mem-
ories. In 1921, while chief of the medical staff
of a new special school for tuberculous children,
the opportunity came to examine and observe
children for the next quarter of a century when
more than 19,000 were examined. One of our
present research problems consists of locating,
inquiring about their health, and examining these
former children. Although many now reside at
distant points, the response to our inquiry has
been most gratifying. When located, some have
inserted special notes on the questionnaires;
others have written long letters expressing ap-
preciation for our efforts to help them when they
were little children. They have vivid memories
of just how they were examined, exactly what
was done, and the advice given them. It is the
receptiveness and retentiveness of the child’s
mind which makes health work for children so
worthwhile.

It is encouraging to learn how these individ-
uals, many of whom had lost one or both parents

Read on the occasion of the presentation of the
William A. Howe Honor Award hi/ the American
School Health Association, November 13, 1957,
Cleveland, Ohio.

or other members of their families from tubercu-
losis, have adhered to the health principles they
were taught as children. Not only have they had
periodic examinations, but they also have pro-
vided them for their children and, in some in-
stances, their grandchildren. Thus, tuberculosis
in their generation has been far less destructive
than it was among their parents and grandparents.

Although equal opportunities exist in all as-
pects of health work, my remarks will be limited
largely to the disease whose germs have taken
refuge in the bodies of more of the 57,000,000
children and personnel of our schools than any
other major pathogenic organism.

APPOINTMENT OF COMMITTEE ON TUBERCULOSIS

When Dr. Charles H. Keene was president of
the American School Health Association in 1934,
he recognized the seriousness of this problem,
not only in the schools but also in the nation.
That year he appointed a Committee on Tuber-
culosis. This disease was then, as now, a serious
national defense item. Dr. Keene realized there
was no possibility of solving the problem quickly,
but he was confident that it could be overcome
through America’s educational system. By en-
listing the support and cooperation of the 1,000,
000 teachers and arming them with the facts
about tuberculosis, that generation of children
should be so protected against and informed
about this disease that they could go through
life suffering less destruction from it than any
previous generation. Moreover, each succeeding
generation of children would become freer from
tubercle bacilli. When Dr. Keene appointed this
committee, generations that had already passed
through the schools were suffering terrible losses
from tuberculosis. Its mortality rate in the nation
as a whole was 58.5 per hundred thousand.
Sanatoriums everywhere were filled to capacity
and numerous persons on waiting lists had to
remain in their homes. Thousands had unknown
but contagious tuberculosis. In cities, 20 per
cent or more of the grade school children and in
colleges, even in the Midwest, approximately one-
third and in some of the eastern states more than
one-half of entering students had been contam-
inated with tubercle bacilli.

MAY 1958

167

It was Dr. Keene’s great hope that his Com-
mittee on Tuberculosis might develop a pro-
gram which would help solve this problem. It
is of historic interest that the first meeting of the
committee was held at Saranac Lake, New York,
in the former residence of Dr. E. L. Trudeau,
who wrote the following in 1905: “Education
should begin by teaching in the public schools
the main facts relating to the transmission of
tuberculosis, insisting in such teachings on the
value of hygienic measures of prevention.”

COMMITTEE DELIBERATIONS AND
RECOMMENDATIONS

During its early meetings, this committee con-
sidered various activities, hoping to find one that
would be practical and could be employed every-
where with assured success. From the beginning,
the members strongly recommended employment
of the tuberculin test among school children
everywhere. One of its activities consisted of
producing a map of the United States indicating
the incidence of tuberculin reactors among
school children. This map was published in the
bulletin of the National Tuberculosis Association
in 1937 with the thought that it would stimulate
interest and activity in tuberculin testing in the
schools throughout the country. Up to that time,
tuberculin testing had been quite spotty, and
not a great deal of information was available.
However, it was anticipated that it would soon
be used extensively and that the map would
show improvement from year to year.

As this project was well underway, almost
fanatic enthusiasm for x-ray film inspection of
the chest without tuberculin testing or any other
phase of an examination swept the country.
Members of the committee, who previously had
had extensive experience with x-ray inspection
and were cognizant of its serious limitations,
knew such a procedure could not possibly solve
the problem. Although attention was called to
these limitations, they were ignored and en-
thusiasm for x-ray film inspection alone ran so
high that tuberculin testing came almost to a
standstill.

For a while, except in a few places, it was
well-nigh sacrilege to mention the tuberculin
test. Even secretaries of tuberculosis associations
referred to the absurdity of administering this
test when the disease could be directly detected
with the x-ray film. They had not been informed
that the ordinary x-ray film of the chest enables
one to visualize only 75 per cent of the lungs;
that areas of disease must be gross and have
adequate consistency to obstruct x-rays before
they cast visible shadows on films; that the

cause of a disease can never be determined from
the x-ray shadows it casts; and that 10 per cent
or more cases of tuberculosis have extrathoracic
locations.

The committee knew that the tuberculin test
is the most accurate diagnostic procedure avail-
able; that it detects tuberculosis long before most
lesions evolve sufficiently to cast x-ray shadows;
that only persons who react to the test become
ill from the disease. Therefore, it was futile to
look for tuberculosis where it does not exist by
making x-ray film inspections of the chests of
persons who do not react to tuberculin.

It seemed likely that the flurry of enthusiasm
for x-ray film inspection alone would soon sub-
side and workers everywhere would return to
a fundamental program. Therefore, the commit-
tee proceeded to recommend tuberculin testing
everywhere despite its unpopularity.

CERTIFICATION OF SCHOOLS PROPOSED

In 1940, it was proposed that a project be de-
vised whereby schools would be certified on the
basis of tuberculosis control work in progress.
Of all the programs that had been discussed
since 1934, certification of schools seemed the
best. If it could be properly organized, more
could be accomplished toward tuberculosis erad-
ication than anything that had ever previously
been employed. It could not only eliminate
clinical and contagious tuberculosis from the
schools, but it could also provide fundamental
information to personnel and students alike
which would be valuable throughout the re-
mainder of their lives.

FIRST SCHOOLS CERTIFIED

It was thought that the certification of schools
project should be given a thorough trial in one
state before it was recommended nationally. A
state was selected in which tuberculin testing
had not been given up entirely for x-ray inspec-
tion. Qualifications for certification were estab-
lished, and the first group of schools was certi-
fied on October 15, 1945. For the period of the
demonstration in that state, the Committee on
Tuberculosis, American School Health Associa-
tion, appointed a state subcommittee consisting
of three physicians. An arrangement was made
whereby this subcommittee worked in close
cooperation with the state Tuberculosis and
Health Association. In that state, certification of
schools was found to be the most effective
method of stimulating interest and promoting
activity in tuberculosis work that had ever been
employed. Moreover, it insured an over-all re-
sponse never previously experienced. It remains

168

THE JOURNAL-LANCET

a major activity of that Tuberculosis and Health
Association.

CERTIFICATION INSURES EXCELLENT RESPONSE

The school certification project has been adopted
by several states. Wherever it has been used, it
has spelled the doom of the tuberculous teacher,
bus driver, other employees, and even the high
school student from spreading tubercle bacilli in
the school and community. The subject of the
project suggests that work is limited to the
schools. In reality, the school is the center of ac-
tivity, but the work is often extended to include
entire communities which the schools serve.
For example, when children are found to react
to the tuberculin test, sources of their infections
are sought among their adult associates, such as
parents, maids, farm hands, and grandparents.
Entire communities become interested in track-
ing down the source of infection in the school
children. This is a first-class method of finding
clinical cases of tuberculosis in the community.
For example. Wood and Mantz sought the source
of infection of tuberculin reactors among the
kindergarten and first grade children in Kansas
City, Missouri. By this method, they located 10
times more contagious cases of tuberculosis than
had ever been found by any other method, in-
cluding mass x-ray surveys. This is not a new
epidemiologic method. It has been in practice
in a few places with excellent results for more
than thirty years. School certification insures its
much wider use.

The program is now so well-established and
has been in operation sufficiently long that there
is no question about its value.

Apparently some members of our own organi-
zation are not aware of the qualifications for
school certification. Some have said that it would
not be possible to adopt this program because
there is so much tuberculosis in their areas.
Certification is based on tuberculosis control
work in progress. The number of tuberculin
reactors found or the number of cases of clinical
tuberculosis discovered has nothing whatsoever
to do with certification. The qualifications only
include testing of 95 per cent or more of the
students and 100 per cent of the personnel, x-ray
film inspection of the chest of all high school and
personnel reactors, and seeking the source of in-
fection of student reactors. Indeed, if every stu-
dent and every personnel member reacted to
tuberculin and 25 per cent had evidence of
clinical disease, such a school could be certified

been met.

A physician wrote that it would be impossible

to certify the schools in his state and, particu-
larly, in the area where he operates a sanatorium
because of the small response. He has admin-
istered the tuberculin test in schools for many
years but only to freshmen and senior high
school students. He stated that the response
varies from school to school and from year to
year and that 80 per cent is considered good.
Experience has proved undeniably that response
of students and personnel is directly in propor-
tion to the amount of effort put into the project
before examinations begin. Apparently, it is
generally true that if an announcement is made
that on a certain day a physician or nurse will
offer the tuberculin test, the response often does
not exceed 50 to 60 per cent. Under such circum-
stances, 80 per cent would be exceedingly high.
However, the 95 per cent plus response among
children and 100 per cent response in personnel
have been readily obtained in many places where
adequate preparation has been made. For ex-
ample, we began testing with tuberculin in a
selected group of city schools in 1926 and re-
tested in the same schools approximately every
ten years to determine the effectiveness of the
general tuberculosis control program in the area.
In 1926, 1936, and 1944, an announcement was
made only a few days before that on a certain
day the tuberculin test would be administered.
The children were to bring signed consents from
their parents. Although the response was reason-
ably good, it was never satisfactory. In 1954, it
was decided to offer these 24 schools certificates
if they met the qualifications. Therefore, an in-
tensive educational campaign was conducted
over a period of about two months. The nursing
staff of the health department and others partici-
pated. They met with parent-teacher organiza-
tions and conferred individually with principals
of schools and other administrators. They dis-
tributed explanatory printed material among par-
ents and the entire school personnel. Education-
al workers of the State Tuberculosis and Health
Association arranged for newspaper articles,
radio and television broadcasts, and a special
printed pamphlet describing the tuberculin test
was distributed to parents and school personnel.
An excellent organization was formed in each
school for the actual testing in which mothers
and health chairmen played an important role.
The whole procedure was thoughtfully and care-
fully developed from the time of its announce-
ment to completion.

School and community pride spurred person-
nel, parents, and the children themselves on to
the certification goal. It served as a powerful
incentive. For example, in the first school tested,

MAY 1958

169

1 teacher did not respond. On the day the tests
were read, seventy-two hours later, she was the
first to appear and requested the tuberculin test,
stating that she could no longer take the goading
of other members of personnel, parents, and even
several children who asked her if she was going
to prevent their school from receiving a certifi-
cate. In another school on the morning the test
was given, a kindergarten teacher informed the
principal that 6 children in her room were ab-
sent. The principal called each mother by tele-
phone and urgently requested that the children
be brought in at least long enough for the test.
Five promptly responded.

When the examinations actually began, the
response was almost unbelievable. Among the
11,984 children, 98.7 per cent responded, and,
in 23 of the 24 schools, 100 per cent of the per-
sonnel was tested and examined.

The only criticism that the committee has re-
ceived came from an organization that was con-
sidering introducing the program but had heard
that this project stimulates so much interest that
more activity would be demanded in the schools
and community than the available manpower
coidd perform. In reality, this was a marvelous
recommendation, as it indicates that certification
of schools overcomes complacency in the public
mind toward tuberculosis eradication. It will be
unfortunate, however, if workers in the afore-
mentioned area do not take advantage of this
opportunity to use the increased interest stimu-
lated by certification to procure adequate funds
to meet the demand.

The educational opportunity in certifying
schools is immense. The two- or three-month
preliminary campaign results in the citizenry
learning much about tuberculosis. This is inten-
sified as the day of testing approaches, which
becomes a red-letter day in the community.
Parents are eager and watching for the results
of the tests of their children. It is a well-estab-
lished fact in pedagogy that the best time to
convey information on any subject is when
people are personally interested. Moreover, actu-
al participation in a project is the best method
of teaching. In the school certification project,
therefore, every personnel member and at least
95 per cent of the students participate.

Where, for any good reason, it is not possible
to test 95 per cent of the students, a Class B
Certificate is available when 80 per cent or more
are tested. This is in recognition of special effort
with the hope that difficulties will he removed so
such schools may later qualify for Class A Certifi-
cates. However, 100 per cent of personnel must
he tested to qualify for a Class B Certificate.

INCOMPLETE PROGRAM DANGEROUS

An unfortunate practice has been in effect in
some places, which consists of testing only child-
ren in certain grades. The logic of such a pro-
cedure is difficult to understand. It fails by more
than 50 per cent to qualify as a good program.
It is hard to believe that such an anomalous
procedure could have been introduced because
of additional work required for a first-class pro-
gram. An experienced nurse or physician can
administer 300 tuberculin tests per hour with
ease. Thus, 1,000 persons can be tested in a
forenoon of a single school day. If this unsatis-
factory procedure is due to lack of funds, an
effort should be made to procure whatever
money is necessary by letting the citizenry of the
community know. There is probably no place in
this country where, if such a problem were
placed before the citizens, adequate funds would
not be forthcoming.

When the qualifications were being prepared
for certification of schools, the committee con-
sidered all such procedures hut decided they
were inadequate.

Moreover, the committee has never approved
relaxing requirements for an individual or a
group of schools. For example, members of
parent-teacher associations and nearly the entire
community involved had difficulty at first in
understanding why the failure of one personnel
member to meet the qualifications should cause
denial of certification of their school. The an-
swer was that, in several instances, the person
or persons who refused to be examined knew
they had pulmonary tuberculosis. When examin-
ation was demanded by the community, the dis-
ease was found. One contagious case of chronic
pulmonary tuberculosis can infect many others.
Therefore, no school can be certified if just one
personnel member refuses examination.

This is an especially good time to continue
or start the school certification project, as H.
R. Smith, long-time livestock commissioner in
Chicago, is soon to publish a book dedicated to
the farm youth of America. It is a history of the
tuberculosis eradication campaign among the
cattle of this country. Attention is called to the
tuberculin test, which has been the sole diagnos-
tic agent, and how official accreditation of coun-
ties which met the qualifications was so valu-
able. This took advantage of local pride, created
interest, and provided information. It required a
large sum of money, hut the American citizenrv
responded when it was sufficiently informed of
the importance of the program. In fact, members
of the veterinary profession have done more
tuberculin testing than any other group. Conse-

170

THE JOURNAL-LANCET

quently, they are better informed about all as-
pects of this test than others. Under the direc-
tion of the United States Bureau of Animal In-
dustry (now Animal Disease Eradication Divi-
sion), 387,803,473 tuberculin tests were adminis-
tered to the cattle of the United States between
1917 and 1957. A total of 4,062,634 reacted. By
the use of the tuberculin test, tuberculosis among
the 95,000,000 cattle of the United States has
been reduced to 0.156 per cent.

What is the tuberculosis situation in the
schools of America today? This question can be
answered quite definitely in only a few states
where extensive tuberculin testing has been
done. In the Dakotas, Iowa, and Minnesota, ap-
proximately 3 per cent of school children have
been found to react to tuberculin. Among per-
sonnel members, the percentage is much higher
but not as high as is generally believed. For
example, in North Dakota, testing of 5,587 re-
vealed that slightly more than 19 per cent of the
personnel members reacted. In Iowa, in the
school year 1955 and 1956, 2,789 personnel
members were tested, and slightly more than 19
per cent reacted. In 1956 and 1957, only 15 per
cent of the 2,173 tested were infected with
tubercle bacilli. Among young personnel mem-
bers, the incidence of infection is low, but among
the older ones, it may run as high as 30 to 40
per cent. The older persons had almost no pro-
tection against either the human or bovine tuber-
cle bacilli when they were children. Therefore,
many are still carrying residual infection. The
young personnel members were much better pro-
tected when they were children, hence the low
incidence of present infection.

In New Hampshire, extensive testing of high
school students revealed only 5 per cent reactors
in 1956 against 60 per cent in 1916. •

From 1949 to 1951, Palmer and associates
tested more than 120,000 white men and women
from 17 to 21 years of age. They included Navy
recruits from all parts of the United States and
students, mostly freshmen, attending colleges
and universities in 17 states. Onlv 8.8 per cent
reacted.

OUR RESPONSIBILITY

The American School Health Association must
accept not only the privilege but also the respon-
sibility for leading the tuberculosis eradication
campaign in the schools of America. A well-
established program has been developed by
which this can be accomplished by working in
close cooperation with all others concerned in
the solution of this problem. If only 3 per cent
of the 27,118,000 grade school children, 5 per

cent of the 12,854,000 high school students, and
20 per cent of the personnel react to tuberculin,
there are now in the schools of this country
1,696,240 persons harboring tubercle bacilli. If
only 1 per cent of the 16,000,000 preschool
children are infected, 160,000 more children
carrying tubercle bacilli will soon enter the
schools. These are conservative numbers, hut
they indicate the magnitude of our problem.

Inasmuch as a tuberculin reaction means that
at least microscopic lesions harbor tubercle ba-
cilli and since clinical and contagious tubercu-
losis develop only in tuberculin reactors, the
importance of finding children and personnel
who are already infected in the schools is ob-
vious.

Since tuberculosis often is a lifetime condi-
tion, tuberculin reactors of today must not only
he examined promptly for gross clinical lesions
but must also be on guard for the remainder of
their lives. Therefore, they should not only be
found while in school but should be apprised of
future potentialities so they may act accordingly.
With modern methods of detecting clinical tu-
berculosis in the presymptom and precontagious
stage and with the present therapeutic armamen-
tarium, there is little excuse for any of those in-
fected today or those who subsequently become
infected to fall ill or die from tuberculosis if
they are properly informed and act accordingly.
Moreover, if they are armed with this informa-
tion on leaving school, they can contribute
mightly in the tuberculosis eradication campaign
in the communities where they subsequently
reside.

In addition to the achievement that is now
possible through tuberculosis work in the schools,
each member of this organization can experience
the greatest satisfaction that comes from helping
children, as is expressed in the following: “He
who helps a child helps humanity with an im-
mediateness which no other help given to human
creatures in any stage of their human life can
give.”

MUST FIND DISEASE WHEN LESIONS
ARE MICROSCOPIC

In the past, the major part of time and effort has
been devoted to seeking advanced cases and try-
ing to repair the damage. Now we are seeking
the disease just as soon as it can be found with
the tuberculin test. This is causing considerable
confusion in the minds of persons accustomed
to thinking of tuberculosis only after it has
caused illness, is contagious, or casts large x-ray
shadows. All chronic pulmonary tuberculosis
starts in a microscopic way when it causes no

MAY 1958

171

symptom, casts no x-ray shadow, and is not
contagions. In this stage, it can be found only
with the tuberculin test. Everyone who reacts to
this test has tuberculosis as surely as those who
are sick from the disease.

Objections have been raised to testing in
schools, because it has been said that so few
cases are found, referring to advanced contagious
tuberculosis. Advanced disease is a rarity among
children except in the occasional high school
student. Therefore, the school certification pro-
gram is not aimed at finding advanced cases but
rather at detecting those who have tuberculosis
long before it has evolved to clinical proportions
and apprising them of its potentialities as well
as seeking the sources of their infection. How-
ever, the examinations required for certification
also find those who may already have advanced
and contagious disease, such as the occasional
high school student and personnel member.

Where certification is instituted and perpetu-
ated, contagious cases are found and removed
from the community. Therefore, the number of
infected children entering school will decrease
from year to year.

JOINT EFFORT AROUSES CITIZENRY

The joint effort of the American School Health
Association and State and Municipal Tuberculo-
sis and Health Associations in certification of
schools awakens practically everyone in the com-
munity to the seriousness of the remaining tuber-
culosis problem. When the project is in progress,
the citizenry becomes so informed as to demand
a total tuberculosis eradication program.

When certification is achieved, the Tubercu-
losis Association has the greatest opportunity in
its entire existence to proceed toward the eradi-
cation goal. Inasmuch as the people whom it
serves are better informed, are more interested,
and are more eager to work than ever before, the
association can then proceed with the follow-up
work on all the tuberculin reactors found among
the students and personnel of the schools.
Enough previously unsuspected cases of con-
tagious disease are detected to keep interest and
activity at a high pitch. The program can then
be extended with ease and rapidity to everv
segment of the population. On several occasions,
certification of schools has led to adoption of
county-wide tuberculin testing campaigns, with
all of the indicated follow-up work.

A good example may be taken from the May
1957 report of Paul C. Williamson, executive
director of the Iowa Tuberculosis and Health
Association. At the end of two years of the
certification project, he said:

1. "Twenty -two Iowa counties have conducted
school certification tuberculin testing programs.
Two of those counties conducted countv-wide
mass tuberculin testing programs for all age
groups.

2. “Reactor registries are being established to
guide the re-examination by x-ray film of all
known reactors and converters.

3. “Physicians from the 22 county medical
societies have participated actively in the pro-
gram.

4. “The programs have involved over 100,000
families. This means that between 300,000 and

400.000 individuals have given personal attention
to important facts about tuberculosis.

5. “Statistically, the information gathered thus
far is of great importance for epidemiologic pur-
poses and is forming a foundation for future
tuberculosis control measures.”

The 1957 report from Minnesota stated: “The
certification program, with its appeal to school
pride, has probably done more than any one
thing to encourage all school employees to have
regular check-ups for tuberculosis. This project
has therefore been an aid in safeguarding child-
ren from possible infection by a tuberculous
teacher, bus driver, or school cook.

“During 1956, in Minnesota, 132,000 school
pupils and more than 10,000 teachers and school
employees in 71 of the state’s 87 counties partici-
pated in the ‘Arms Against Tuberculosis’ pro-
gram. In 1957, of the 532 schools certified, 300
reported a 100 per cent response of pupils.

“Certification of schools is another excellent
means for interesting pupils, parents, and the
school personnel in the program to safeguard
all against tuberculosis.”

James J. Swomley, executive director. North
Dakota Tuberculosis and Health Association
said: “It is my belief that our school certification
project has ( 1 ) given us a program of health
education in the schools second to none, (2)
given us an inexpensive case-finding method that
is particularly valuable to areas of low tuber-
culosis incidence where other forms of case-
finding may no longer be practical, and (3) im-
proved our public relations by putting before
the public a tangible program with popular
appeal.”

John Casebolt, executive director of the Mon-
tana Tuberculosis Association said: "In one small
county in which we have been doing a pilot
study, there is an enrollment of approximatelv

4.000 students. We were successful in getting
the cooperation of every physician in the area,
the use of 20 volunteer nurses, and an unlimited
number of persons in the education field. I am

172

THE JOURNAL-LANCET

of the opinion that had it been needed in this
small area, we eoidd have called up 2,000 volun-
teers to assist in this program.”

A SERIOUS PROBLEM WITH SOLUTION AT HAND

It has been estimated that in approximately 5
per cent of persons who react to tuberculin, clini-
cal tuberculosis will at some time develop. This
means that among students and personnel now
in the schools of the United States, the disease
will evolve to clinical proportions in 84,812 be-
fore completing their span of life. The estimate
of a 5 per cent breakdown among tuberculin
reactors is probably too low. A careful analysis
by Bogen places it at 50 per cent.

The large number of persons now in the
schools who are destined to break down with
clinical tuberculosis can nearly all be prevented
from becoming seriously incapacitated and dis-
seminating tubercle bacilli to others. However,
if they are not identified and if the careful obser-
vation required for this accomplishment is not
done, their present infections can result in much
illness, death, and spread of disease to others.

Clinical disease may be postponed to old age.
In fact, most of the illness and death now occurr-
ing from tuberculosis in this country are among
persons in the upper age brackets who, as in-
fants and school children, had no protection
against tubercle bacilli. Once infected they were
not apprised of the dangers ahead. Thus, tre-
mendous numbers of their generation have died,
and they, the old survivors, are still paying a
terrible price in health and life as the result of
infections acquired early in life. Through the
School Certification Project, provision has been
made to protect present and future generations
of children against such disaster.

The American School Health Association has
done excellent work, but it has a tremendous
task ahead to keep our school populations in-
formed in order to exhibit the spirit of helpful-
ness referred to by Sir Walter Scott when he
said, “The race of mankind woidd finish did they
cease to help each other; all therefore that need
aid have a right to ask it from their fellow mor-
tals; none who hold the power of granting aid
can refuse it without guilt.”

Ardmore disease is an extremely infectious epidemic illness of the reticulo-
endothelial system, characterized by upper respiratory symptoms, prolonged
malaise, general adenopathy, painful hepatosplenomegaly, and a tendency to
persist as a chronic, smoldering illness of several months' duration.

Although ardmore disease resembles infectious mononucleosis, heterophil
agglutinations are negative and no atypical lymphocytes are found in the blood
smear. Jaundice is almost never observed.

In an outbreak affecting 63 patients at Air Force bases in Ardmore, Okla-
homa, and Lubbock, Texas, the most common complaint was severe pain in
the lower chest or upper abdomen, which was increased bv breathing or jar-
ring. Scratchy sore throat usually preceded abdominal pain by a day or so.
General myalgia, frontal headache of varying intensity, and nausea were com-
mon; vomiting was rare.

Patients usually appear acutely ill with sensitive posterior lymph nodes and
extreme abdominal tenderness. The liver is palpable in 70 per cent on admis-
sion and in 92 per cent during hospitalization. Figures for immediate and even-
tual splenomegaly are 28 per cent and 48 per cent, respectively. One half of
patients have some fever.

Laboratory studies are not diagnostic. Lymphocytes are sometimes in-
creased. Liver function tests show much less derangement than the symptoms
suggest. Cephalin-cholesterol flocculation is elevated in most cases, and Brom-
sulphalein retention is increased in three-fifths. Albumin-globulin ratio is occa-
sionally reversed.

William L. Wilson, M.D., Hahnemann Medical College, Philadelphia; Charles D. Williams,
M.D., Charlotte, North Carolina; Saul L. Sanders, M.C., Ardmore Air Force Base, Ardmore, Okla-
homa; and R. P. Warner, M.D., New York City. Arch. Int. Med. 100:943-950, 1957.

MAY 1958

173

Viruses and their Relationship to Cancer

CHESTER M. SOUTHAM, M.D.

New York City

Virology and oncology are related in three
broad areas of medical interest: oncogenesis,
oncolvsis, and intracellular chemistry and meta-
bolism. These relationships have no immediate
application in clinical medicine, but they carry
implications for the understanding, prevention,
and treatment of human cancer which demand
the attention of research workers and practi-
tioners alike. To orient this discussion, some gen-
eral characteristics of viruses and virus infection
will be briefly reviewed. The brief bibliography
includes only selected studies and reviews in
which the interested reader can find more detail
and complete documentation.

CHARACTERISTICS OF VIRUSES AND VIRUS INFECTION

A virus may be defined as a submieroscopic
obligate intracellular parasite. The word parasite
indicates its status as a living organism and its
reliance on its host for sustenance. Its obligate
intracellular nature indicates its relative size and
the fact that it has metabolic inadequacies at the
level of intracellular metabolism. All viruses
studied so far contain nucleic acid and protein.
Some plant viruses, insect viruses, and bacterial
viruses contain no other constituents. The pro-
tein forms a sheath around a core of nucleic acid.
The nucleic acid of bacteriophage is deoxyribose
nucleic acid (DNA), while that of the plant
viruses is ribose nucleic acid (RNA). Animal
viruses are more complex. They may contain
lipids, carbohydrates, and enzymes. They may
contain DNA or RNA or, possibly, both. Sketchy
evidence suggests that viruses which propagate
within the nucleus have DNA, and intracyto-
plasmic viruses have RNA. The inability to pre-
pare animal viruses without contamination by
host cell constituents has hampered chemical
analyses.

Chester m. southam is head of clinical and onco-
genic virology at the Sloan-Kettering Institute for
Cancer Research, Neiv York City.

From the Clinical and Oncogenic Virology Sec-
tions, Sloan-Kettering Institute and the Chemothera-
py Service of Memorial and James Ewing Hospitals,
Memorial Center for Cancer and Allied Diseases,
New York City.

Since the intracellular state is obligatory for
viral propagation, it follows that virus anabolism
must utilize host cell constituents, and, since a
virus has few if any enzymes of its own, it com-
mandeers these nutrients at a relatively complex
biosynthetic level. This loss of intracellular
nutrients might be detrimental to the host cell,
or the cell might not be noticeably affected if the
demands of the virus are within the capacity of
the cell to supply. A virus, however, does not
merely accumulate host metabolites. It molds
them into its own protoplasmic structure. There-
fore, we. can also conceive that a virus might
synthesize metabolites which, if allowed to ac-
cumulate, would restrain host cell metabolism or
propagation or, conversely, might goad the cell
into greater activity. These various conditions
are analogous to parasitism, commensalism, and
symbiosis at a cellular level. If the virus-infected
cell is part of the metazoan host, these conditions
would be evidenced as tissue destruction, in-
apparent infection, or tissue proliferation, res-
pectively.

The origin of viruses has been the subject of
considerable philosophic speculation. One view
is that viruses are degenerate microbes which
have given up their birthright of independent
life for the effortless life of parasitism and by a
sort of Lamarkian evolution have lost those pro-
toplasmic constituents which are superfluous in
their protected environment. The opposite view
holds that viruses originated from cell organelles
which have acquired partial autonomy. In the
present discussion, it matters little whether a
virus is regarded as a beloved parasite or a re-
jected offspring.

Virus infection at the cellular level consists of
several successive steps (figure 1). Adsorption is
a reversible stage in which the virus becomes
attached to the cell membrane. Penetration is an
irreversible stage during which the virus pene-
trates into the cell. The entire virus particle does
not necessarily penetrate into the cell. Studies
of the T even phages of Escherichia coli suggest
that the viral nucleic acid alone penetrates the
cell wall and initiates infection. Viral replication
may yield complete virus units or incomplete
forms, which are not demonstrable bv direct

174

THE JOURNAL-LANCET

VIRUS INFECTION OF A CELL- SCHEMATIC

PROLIFERATION
(REPLICATION)

AnRORPTiON— *■ PENE" -.PROLIFERATION - R

ADSORPTION yRATION^ 1 DCDI ir.ATinMl inANbrtn

Fig. 1. Schematic representation of the stages of virus
infection of a cell. The scheme is based largely on studies
of bacteriophage, but sufficient data are available con-
cerning animal and plant viruses to justify the assump-
tion that at least most of the indicated steps and variables
apply generally in virus infections.

isolation or serologic technics. Transfer of virus
into new cells may accompany cell division, with
a parceling of virus particles into both daughter
cells, or may follow release of virus particles into
extracellular fluids. Release commonly involves
destruction of the cell (cytolvsis) but can also
occur without cell damage by such mechanisms
as accomplish disposal of cell waste (reverse
pinocytosis). When the virus becomes extracell-
ular, the cycle of cellular infection starts again.

At the host level, virus infection must also be
considered in several steps. Inoculation is that
process by which the virus is introduced into or
onto the multicellular host. Incubation is the
time during which the process of intracellular
infection and transfer is occurring but before the
host manifests any infection. The systemic phase
of infection is that period when virus is widelv
disseminated throughout the host by distribution
through body fluids. A systemic phase may not
occur in all viral infections but is more frequent
than previously suspected. Viremia is the pres-
ence of virus in the blood and, so, is often syn-
chronous with the sytemic phase of infection.
Tropism is the phenomenon of selective distri-
bution of viruses to particular tissues. Examples
of dermatotropic, hepatotropic, and neurotropic
viruses are well known. The characteristic mani-
festation of a virus infection is usually a reflec-
tion of specific tropism, but tropism does not
inevitably result in damage at the site of locali-
zation. Disease is that condition of host malfunc-

tion which results from tissue damage (destruc-
tion or proliferation) by the virus and the reac-
tions of the host to the virus infection. Virus in-
fection can occur without producing disease. In
fact, inapparent virus infections are much more
frequent than virus-induced disease. Antibody
formation is a host response to the presence of
the virus, and the appearance of circulating anti-
bodies is roughly coincident with the disappear-
ance of virus from the extracellular fluids. Virus
may persist and propagate within cells even
in the presence of circulating antibodies, which
are generally incapable of penetrating the cell
membrane. Such intracellular virus may cause
no apparent ill effect at the cellular or host level.
It may cause chronic disease. At any time,
changes may occur in the virus or host which
upset the delicate balance of inapparent infec-
tion and cause delayed pathology. This woidd
be interpreted, in clinical terms, as an exacerba-
tion of disease or, if the infection had previously
been inapparent, as primary disease following a
long incubation period. Pathogenic virus infec-
tion may be followed by a period of repair which
constitutes the major part of the “clinical’' pic-
ture.

Thus, the patterns of virus infections may be
overt or inapparent; acute, chronic, or latent; and
destructive or proliferative. The patterns may
vary not only according to the species of path-
ogen and host but also in different individuals
and at different times in the same individual.
Possible patterns of virus infections are dia-
gramed in figure 2.

Transmission of a virus from host to host may
be horizontal or vertical. Horizontal transmission
includes those routes with which we are most
familiar— droplets, fomites, arthropods, and so
forth. Vertical transmission denotes passage from
parent directly to offspring during ontogeny. It
is recognized in the transmission of Rickettsia
through successive generations of their arthropod
host and in infections with Bittner’s milk factor
and is postulated for Gross’s leukemia virus of
AK strain mice.

Adaptation, although probably a property of
all protoplasm, is particularly evident in viruses.
Under suitable conditions, a virus may change
in its abilitv to localize or cause pathology in
various tvpes of cells or tissues or may even
change in its infectivity for various hosts. Al-
though little is known about the mechanics of
viral adaptation, it might be postulated that this
involves a change in the genetic material ( nucle-
oprotein) of the virus due to the change in the
source materials from which it is derived. Gen-
etic changes induced by the accessibility of dif-

MAY 1958

175

PATTERNS OF VIRUS INFECTIONS

PRIMARY FATE OF
INFECTION VIRUS

SUBSEQUENT STATES

INAPPARENT VIRUS COMPLETE

INFECTION ^GONE CURE

LATENT
INFECTION
(APPARENT
S CURE)
VIRUS ^

PERSISTS

DISEASE

(OVERT

INFECTION)

D

CHRONIC S?'

DTSEASF *

EXACERBATION

Fig. 2. Patterns of virus infections in
a metazoan host. All indicated possi-
bilities are well-established in either
natural or experimental virus infec-
tions of man and mice.

ferent DNA (transformation or recombination)
have been repeatedly observed in bacterial cells
and in some bacteriophage systems.

VIRUSES AS ONCOGENIC AGENTS

The most basic fact in any consideration of
viruses as causes of cancer is that some viruses
do cause neoplasms. The list has continuously
enlarged since the reports of Ellerman and Bang
in 1908 and Rous in 1911 that leukemias and
sarcomas of chickens are caused by filterable
viruses. A list of virus-caused neoplasms is pre-
sented in table 1. More than 10 examples of
virus-induced tumors are firmly established bv
repeated critical investigations of the viral nature
of the causative agent and malignant neoplastic
nature of the pathologic lesion. Many more ex-
amples have been reported and are listed in the
table as “probable” because published data pre-
sent less convincing information on the malig-
nancy of the tumor or the viral nature of the in-
ducing agent or because confirmatory reports
from other laboratories are still lacking. The list
is impressive not only for the number of virus-
induced tumors but for the wide range of animal
species represented. The list is also remarkable
for the absence of man.

Although no virus which is oncogenic for man
has ever been recognized, two phenomena de-
serve mention as possibly related conditions.
Viruses which stimulate nonmalignant cellular
proliferation in man are well known. Verruca
vulgaris and molluscum contagiosum are benign
neoplasms of viral origin. The early lesions of
herpes zoster, varicella, trachoma, and certain
other dermatotropic viruses are characterized by
cellular proliferation. The leukemoid reaction
which occasionally accompanies virus infections.

such as mumps, is also a cellular hyperplasia
caused by virus, although it is not known
whethef the effect on hematopoiesis is indirect or
due to actual virus infection of hematopoietic
tissues.

On the basis of what is already known about
oncogenic viruses of animals, it is clear that the
relationship between host and virus in an onco-
genic virus infection differs in many respects
from infection by such viruses as equine enceph-
alitis or influenza, which we are accustomed to
consider as typical viruses.

Oncogenic virus transmission may be by routes
which are now considered unusual. For example.
Gross’s leukemia virus of AK mice apparently has
a vertical transmission from mother to offspring.
Bittner’s virus is transmitted through the mother’s
milk to the infant mice and, in addition, can ap-
parently be transmitted through spermatozoa.

A long incubation period is characteristic of
some virus-induced tumors. Gross’s leukemia
virus and Bittner’s virus (milk factor) both have
incubation periods of about one year, which is
probably longer than the average life span of
wild mice. Such long incubation periods implv
that the virus exists intracellularlv for a long time
without causing overt pathology. It suggests
that, under natural conditions, there may be an
extremely high incidence of inapparent infection
and that the development of overt disease may
necessitate coincidental stresses. The role of
secondary etiologic factors is recognized in cer-
tain virus infections of man. Recurrent herpes
simplex is characteristically activated by an up-
per respiratory infection or mechanical trauma.
The tendency for paralytic poliomyelitis to occur
in an extremity which has been traumatized dur-
ing the early phase of infection is quite well doc-

176

THE JOURNAL-LANCET

TABLE 1

PARTIAL LIST OF VIRUS-CAUSED TUMORS

Animal

Tumor

Discoverer

Virus designation and remarks

Generally

accepted group

Viral and neoplastic characteristics conclusively established

Chicken

Lymphomatosis

Ellerman? |

A complex of many virus strains

Chicken

Erythromyeloblastosis

Ellerman & Bang ^

with obscure interrelationships

Chicken

Sarcoma I

Rous

Rous sarcoma virus

Rabbit

Papilloma to carcinoma

Shope

Papillomas often proceed to

carcinomas

Mouse

Breast cancer

Bittner

Bittner’s milk factor

Mouse

Leukemia

Gross

In newborn AK mice only

Mouse

Leukemia

Friend

Transmissible in adult mice

Mouse

Leukemia

Graffi

Probable group

Viral and neoplastic

nature not fully established

Fruit flv

Melanosis

Burton & Friedman

PNeoplastic growth

Pike, perch, etc.

Lymphocystic disease

VVeissenberg

Pickerel frog

Renal tumor

Lucke

Frog

Lipoma

Thomas

Usually a benign tumor

Rabbit

Myxoma

Sanarelli 1

Neoplastic or inflamatory?

\

Viruses are closely related

Rabbit

Fibroma

Shope J

serologically

Squirrel

Fibroma

Kilham et al.

Deer

Fibroma

Shope

umented. Similarly, it has been shown that intra-
venous administration of Shope papilloma virus
or Rous sarcoma virus causes tumors at sites of
mechanical or chemical irritation. Genetic and
hormonal factors are also of great importance in
determining host response to virus infections.

It may be difficult to demonstrate the presence
of an oncogenic virus in tumor tissue. This may
be due to unsuitable test systems, but even when
suitable technics are available, it may be im-
possible to detect a virus in such thoroughly
studied tumors as Shope papilloma and Rous
sarcoma. This apparent periodic disappearance
of the virus has given rise to the concept of a
“masked” virus, which is assumed to be an in-
complete virus particle analagous to the pro-
phase of the bacterial viruses. It is conceivable
that viruses actually are not present in some
virus-induced tumors and that the neoplasm is
a continuing reaction to an etiologic agent which
has since disappeared. Such a hypothetical sit-
uation has its parallel in the glial nodules of post-
encephalytic parkinsonism or the cirrhosis and
nodular regeneration which may follow infec-
tious hepatitis.

The phenomenon of virus adaptation has been
demonstrated in oncogenic viruses, particularly

with the Rous sarcoma virus which has been
adapted to growth in several species of fowl
other than chicken. Evidence of recombination
has been presented for two oncogenic viruses. It
has been reported that Lucke’s kidney tumor
virus of frogs, after passage through salamanders,
caused muscle tumors instead of kidney tumors
on subsequent reinoculation into frogs. A mix-
ture of DNA from killed myxoma virus with live
fibrosarcoma virus caused myxomas when rein-
oculated into rabbits. The possibility of adap-
tation and recombination in oncogenic viruses
could theoretically give rise to an almost infinite
variety of viruses and tumors.

A problem which must be faced if we are to
consider the possibility of virus-induced cancer
in man is the apparent lack of antigenicity of
spontaneous cancer, because virus infections
with which we are now acquainted, including
some oncogenic virus infections, are followed bv
the production of serum antibodies. However,
this obvious problem is probably not real. First,
it is not necessarily true that spontaneous cancer
is not antigenic. Nonanti^enicity is generally
assumed because of clinical familiarity with pro-
gressive human cancer. It can be postulated, but
never proved, that cancer does not develop in

MAY 1958

177

many persons exposed to oncogenic agents be-
cause they developed adequate specific immun-
ity, while only in the exceptional individual is
the agent able to produce overt disease. The
presence of specific immunity can neither be
proved nor disproved until an immunologic test
system is available, and this requires specific
antigens. Even if a circulating antibody is pres-
ent, it cannot destroy a virus which remains in-
tracellular (transferred through cell division).
Even if it is true that cancer produces no cir-
culating antibodies, it does not follow that cancer
is nonantigenic, since antibodies are usually un-
detectable in the presence of antigen excess— the
state one would expect in the patient with un-
cured cancer— and circulating antibodies are
often not demonstrable even in situations of
known specific immunity, such as allergic states.
Second, even if spontaneous cancer is truly non-
antigenic, the presence of a virus cannot be ex-
cluded because the virus may be antigenically
compatible with the host. Extensive studies with
Bittner’s milk factor and with Rous sarcoma virus
suggest that this situation exists when these
viruses are in their natural hosts. Third, since
oncogenic viruses may enter their hosts during
fetal life, they may be nonantigenic by virtue of
acquired tolerance, as has been demonstrated
for tissue antigens by Billingham and Medewar
and co-workers.

In trying to assess without prejudice the poss-
ible importance of viruses in human oncogenesis,
it must be recognized that cancer is not one dis-
ease but many. It is no exaggeration to say that
the diseases which we lump together under the
term cancer are as diverse in their manifestations
and course as are the infectious diseases. Quite
conceivably, each of these neoplastic diseases is
a separate etiologic entity. There may be no
simple etiology for neoplastic diseases, but an
interplay of several etiologic factors may act in
concert. Finally, it must be recognized that fail-
ure to isolate a virus is no proof of the nonexis-
tence of a virus.

In summary, it may be said that although there
is no proof that viruses have an etiologic relation-
ship to human cancer, neither is our present
knowledge of cancer or of viruses inconsistent
with the hypothesis that viruses may be respon-
sible in whole or in part for some or even all
cancer in man.

viruses as oncolytic: agents

Interest in the capacity of viruses to destroy
tumor tissue had its inception in clinical obser-
vations of “spontaneous” tumor regression in
man following coincidental virus infections. De-

Pace, in 1912, observed regression of cervical
carcinoma in a woman who had Pasteur treat-
ment for rabies after a dog bite. Hoster observed
a remission of Hodgkin’s disease in a patient with
infectious hepatitis. Regression of a facial mel-
anoma in a patient given rabies vaccine was ob-
served by Pack and associates. Several other ex-
amples of transient tumor regression temporally
related to various virus infections have also been
reported. These observations prompted the de-
liberate induction of similar virus infections in
other patients with cancer. However, the result-
ing tumor regressions, if any, were insufficient to
stimulate continued work.

In the laboratory, Levaditi, Nicolaw, and others
observed as early as 1922 that vaccinia and her-
pes simplex viruses grew well in several tumors
of mice, but the work of Moore was the first con-
certed attempt to study viral oncolysis in ex-
perimental animals. The contributions of many
other workers to this field have been outlined
in Moore’s recent review.

Many viruses, notably, Russian encephalitis.
West Nile, Ilheus, Mengo, Bwamba, Semliki,
and Bunyamwera have shown impressive oncoly-
tic activity against some types of experimental
animal tumors. Oncolysis is accompanied, with-
out exception, by high concentrations of virus in
tumor tissue, even though the virus is inoculated
at sites distant from the tumor. When used to
treat tumors of mice, these viruses usually cause
death. The oncolytic effect, however, is unre-
lated to the severity of illness because if a virus-
resistant host is used— an animal which is in-
fected but not killed by the virus— tumor inhibi-
tion can be produced without ill effect on the
host. Conversely, many lethal viruses have no
antitumor effect. Curative results with virus
treatment of tumors have been demonstrated
with sarcoma 180 in a virus-resistant strain of
mice treated with Russian encephalitis virus, in
myxoma and fibroma of rabbits treated with
Semliki forest virus, and in lymphomatosis of
chickens treated with a variety of arthropod-
borne viruses.

The ability of viruses to inhibit various tumors
forms a spectrum which is unpredictable on the
basis of virus type or tumor type by any pre-
sently known criteria. The effects are, however,
consistently reproducible, even to the extent that
the tumor-inhibiting characteristics of a virus
against a spectrum of tumors might be utilized to
identify a virus.

By serial passage of viruses in a single type of
tumor, it has been possible to increase the onco-
lytic capacity of a virus for a given type of tumor
and even to produce an adapted strain of a high-

178

THE JOURNAL-LANCET

Fig. 3. Regression of skin metastases of lymphangiosarcoma due to West Nile (Egypt 101) virus infection. (Left).
Papular lesions on arm ninteen days after virus administration. Regression was already apparent by this time, but
no comparable view was photographed prior to treatment. (Right). Further regression three and one-half months
after virus. Virus was demonstrated in tumor biopsies taken on the eighth day.

ly oncolytic virus for a tumor which was origi-
nally unaffected by that virus.

The demonstration of viral oncolysis in animal
tumors stimulated interest in studies with human
cancer. The development of technics for the
laboratory cultivation of human cancer in con-
ditioned animals and in tissue cultures permitted
such studies at the laboratory level. Moore and
co-workers have demonstrated destruction of
human cancer cells by viruses of various types in
tissue culture, in embryonated eggs, and in cor-
tisone-treated rats and hamsters. As with the
experimental tumors of mice, these results form a
reproducible spectrum that is unrelated to cell
type or viral characteristics. The effect of viruses
on a given cancer cell in one system is paralleled
by the effects observed in other systems using the
same cell line. These studies have, however, been
hampered by the many variables involved in
these systems and by the extreme susceptibility
of the experimental animals in which human can-
cer cells are grown to viruses. Attempts to in-
crease oncolysis by serial passages in human can-
cer cells in tissue culture have been disappoint-
ing to date. However, Heubner and co-workers
have reported impressive adaptation of several
adenoviruses and Coxsackie viruses against He-
La cells by serial passage using cortisonized rats
as the tumor-bearing host.

In the discouraging problem of treating in-
curable human cancer, it was logical to attempt
to use for therapeutic purposes the oncolytic
capacity of viruses of low pathogenicity. A

therapeutic trial of several such viruses was initi-
ated in 1950 at Memorial Cancer Center. Tumor
regression which could be objectively evaluated
has occasionally been observed, but the oncolytic
effect has seldom been sufficient to substantially
benefit the patients. The most impressive result
of these studies, aside from the unprecedented
opportunity for virologic and serologic studies
on pedigreed virus infections in man, was the
demonstration of a high frequency of onco-
tropism, with or without oncolysis, and the fact
that many viruses could be administered to
human beings with minimal or no evidence of
disease resulting from the virus infection. Some-
what similar studies using the adenoviruses were
initiated in 1954 at the National Cancer Institute
in patients with advanced cancer of the cervix.
Here, too, results provided evidence that these
viruses possess a tumor destructive capacity, but
effects were seldom of therapeutic importance.

The most impressive tumor inhibiting effects
so far in the studies at Memorial Cancer Center
have been with the Egypt 101 isolate of West
Nile virus against neoplasms of the reticulo-
endothelial system. Several patients with adeno-
carcinoma of the large bowel have also shown
slight response, but, in general, there are insuf-
ficient data to state that anv one category of can-
cer is most susceptible to the viruses which have
been tested to date. Recently, a patient with
lymphangiosarcoma experienced almost complete
hut temporary tumor regression after Egypt 101
virus infection (figure 3).

MAY 1958

179

TABLE 2

PARTIAL LIST OF AGENTS WITH BOTH ANTIVIRAL AND ANTITUMOR ACTIVITY0

Chemical category

- Antiviral activity
Bacterio-
phages

_ ...

—

■■

Plant

viruses

Animal

viruses

Man

- Antitumor activity
Mouse

Other

Purines:

Amino substituted purines

+

+

+

8-aza purines

+

O

o

O

+

+

Pyrimidines:

Diazo pyrimidines

+

+

5 halogenated pyrimidines

o

+

+

Hh

+

Phenoxvthio pyrimidines

+

+

Folic acid antagonists:

Cblorphenyl pyrimidines

+

+

+

Benzimidazoles

o

+

+

o

+

+

4-amino folic acids

+

o

+

+

+

Other vitamin aimlogues:

Sulfonamides

+

+

Pyridoxine analogues

o

+

+

o

+

Amino acids:

Methionine analogues

+

+

o

+

+

T h iosem icarbasones:

+

+

Antibiotics:

Netropsin

+

+

+

Fumagillin

+

+

Statements of antiviral and antitumor activity are based on in vivo tests, but criteria for evaluation vary widely in different systems.
Published statements of activity have been accepted uncritically and are gleaned principally from the reviews cited in bibliography.
If any activity is reported, the agent is tabulated as If negative tests are reported, the designation is O. No entry means no data
known by the author. A ±: designation is used for human tumors only, to indicate suggestive or minimal antitumor activity, because
a more critical evaluation seemed desirable in man.

The possibility that viruses may be found or
produced which will cause tndy worthwhile re-
gression of human cancers cannot be disregard-
ed. The results in experimental animals have
been so impressive and the occasional tumor re-
gressions in patients have been so tantalizing
that the study certainly merits continued investi-
gation. Attempts to adapt viruses in the direc-
tion of greater oncolytic capacity and lessened
pathogenicity is a hopeful area for continued
study, although the possibility must be recog-
nized that each patient’s cancer cells are so in-
dividualized that adaptation might be effective
only for a single cell type. Basic research in this
area may have even greater importance than the
immediate clinical application, since it seems
clear that selective oncotropism is a demonstra-
tion of the difference between normal and cancer
cells in some property at the intracellular level.
Probably, as studies on cellular and viral metabo-
lism continue, differences between normal and
neoplastic cells will be pinpointed which can be
exploited by more conventional means of cancer
chemotherapy. The possibility that this tvpe of
study will also furnish leads in the field of anti-
viral chemotherapy should not be overlooked.

OTHER RELATIONSHIPS BETWEEN
VIRUSES AND CANCER

The thesis that the cancer cell differs essentially
from its normal counterpart because of differ-
ences in cellular metabolism and the fact that
viruses enter into or partake of intracellular
metabolic processes in reproducing themselves
implies a similarity between virus -infected cells
and cancer cells in that both are similar to but,
nevertheless, differ significantly from the normal
cell. The study of the metabolic processes of
viruses and the effect of various metabolites and
antimetabolites upon virus propagation thus have
potential cariy-over to the understanding of and
selective interference with the metabolism of
the cancer cell. Therefore, the problem of cancer
chemotherapy would seem to be closely paral-
leled by antiviral chemotherapy. This suspected
relationship is further emphasized by the fact
that several antimetabolic compounds which in-
terfere with nucleic acid synthesis demonstrate
both antineoplastic and antiviral activity. Table
2 lists several examples.

An interesting parallel between virus infec-
tions and neoplasms is that both are essentially
intracellular pathologic processes without pri-

180

THE JOURNAL-LANCET

mary extracellular abnormality. It follows that
even if a specific antibody is formed or passively
administered, it would have no effect upon either
process as long as the abnormal materials re-
mained intracellular.

There are superficial similarities between neo-
plastic and viral diseases which suggest the exis-
tence of natural resistance against both types of
disease. The variable course of cancer in differ-
ent individuals might be interpreted as either
fluctuation in the aggressiveness of the cancer
cell or as fluctuation of host resistance. The vari-
ation in cancer incidence at various ages suggests
the possibility that host resistance to certain
types of cancer varies with age, although alter-
native explanations are equally attractive. In
parallel with these variations in neoplastic dis-
eases are well-known variations in resistance to
virus diseases. Baby chickens are extremely
susceptible to infection with numerous viruses
of the arthropod-borne group but rarely succumb
to these infections. After the age of 3 or 4 weeks,
however, chickens rapidly become completely
resistant ( not a specific immunity ) to these same
viruses. Conversely, lymphocytic choriomenin-
gitis virus propagates well in the brains of suck-
ling mice but causes no apparent disease, al-
though, in adult mice, it is rapidly fatal. The
reverse phenomenon is equally well known in
the Coxsackie group of viruses, which are lethal

CHARACTERISTICS OF VIRUSES AND VIRUS INFECTIONS

1. Burmester, B. R.: Routes of natural infection in avian

lymphomatosis. Ann. New York Acad. Sc. 68:487, 1957.

2. Fraenkel-Conrat, H.: Structure and infectivity of tobacco

mosaic virus. Harvey Society Lectures, Series 53, 1957 (in
press ) .

3. Herriott, R. M.: The virulent T (even) phages of Escheri-
chia coli B., in The Chemical Basis of Heredity. Baltimore:
Johns Hopkins Press, 1957, p. 399.

4. Lederberg, J.: Viruses, genes, and cells. Bact. Rev. 21:

133, 1957.

5. Lwoff, A.: Control and interrelationships of metabolic and

viral diseases of bacteria. Harvey Society Lectures, Series 50,
1954-55.

6. Rivers, T. M.: General aspects of viral and rickettsial infec-
tions, in Viral and Rickettsial Infections of Man. Philadel-
phia: J. B. Lippincott Co., 1952, p. 1.

7. Southam, C. M., and Moore, A. E.: Induced virus infections
in man by Egypt isolates of West Nile virus. Am. J. Trop.
Med. 3:19, 1954.

ONCOGENIC viruses

8. Beard, J. W., Sharp, D. G., and Eckert, E. A.: Tumor vi-
ruses. Advances in Virus Res. 3:149, 1955.

9. Bittner, J. J.: Recent studies on the mouse mammary tumor
agent. Ann. New York Acad. Sc. 68:636, 1957.

for suckling mice but cause no pathology in adult
mice. An equally great variability in response to
a given virus is found in individuals within the
same age group. This is most dramatically ap-
parent in man, for example, in poliovirus or Jap-
anese B encephalitis infections, people exposed
to presumably equal inocula of virus may show
no infection, infection without clinical illness,
illness with complete recovery, persistent patho-
logy, or death may ensue.

These apparent similarities between viral in-
fections and cancer may not be susceptible to
direct investigative comparison, but they point
up the importance of basic research in all fields
because of the possibility that advances in any
branch of science may have eventual application
to problems of immediate importance to man.

CONCLUSION

Finally, oncology and virology have many char-
acteristics and problems in common which are
of great research interest, and, although these
problems may now be principally of academic
interest, we may hope and expect that research in
these two fields will lead to findings of clinical
importance.

Original work referred to in this article was supported
in part by grants from the National Cancer Institute,
National Institutes of Health, United States Public Health
Service, and the Phoebe Waterman Fund.

10. Dmochowski, L.: The milk agent in origin of mammary tu-
mors in mice. Advances in Cancer Res. 1:103, 1953.

11. Gross, L.: Studies on nature and biological properties of a

transmissible agent causing leukemia following inoculation
into newborn mice. Ann. New York Acad. Sc. 68:501, 1957.

12. Oberling, C., and Guerin, M.: Role of viruses in production
of cancer. Advances in Cancer Res. 2:353, 1954.

ONCOLYTIC VIRUSES

13. Moore, A. E.: Effects of viruses on tumors. Ann. Rev. Mi-

crobiol. 8:393, 1954.

14. Moore, A. E.: Oncolvtic properties of viruses. Texas Reports
on Biol. & Med. 15:588, 1957.

15. Smith, R. R., and others: Studies on use of viruses in treat-
ment of carcinoma of the cervix. Cancer 9:1211, 1956.

16. Southam, C. M., and Moore, A. E.: Clinical studies of vi-
ruses as antineoplastic agents, with particular reference to
Egypt 101 virus. Cancer 5:1025, 1952.

ANTIVIRAL AND ANTICANCER AGENTS

17. Anon.: Cancer chemotherapy, a bibliography of agents

1946-1954. Cancer Res. 16(10):267, 1956.

18. Gellhorn, A., and Hirschberg, E. (editors): Investigation of
diverse systems for cancer chemotherapy screening. Cancer
Res. (supp. 3) 1955.

19. Matthews, R. E. F., and Smith, J. D.: Chemotherapy of
viruses. Advances in Virus Res. 3:51, 1955.

MAY 1958

181

General Principles for Drug Therapy
in Childhood Epilepsy

SAMUEL LIVINGSTON, M.D.

Baltimore, Maryland

The following general principles for drug
therapy in childhood epilepsy are based on
the follow-up studies of approximately 9,000
children with epileptic seizures of all types. All
of these children have been observed for ten
to twenty years.

1. Treatment should he instituted as soon as
the diagnosis has been established. This is the
most important aspect of the treatment of epi-
lepsy because, in most cases, the degree of suc-
cess in the control of seizures bears a direct re-
lationship to the duration of the epilepsy. The
longer the epilepsy has continued, the less likely
it is that a satisfactory result will be obtained,
regardless of the type of therapy instituted. In
addition, it is important to prevent a recurrence
of seizures, particularly those of long duration,
because such seizures can produce irreversible
brain damage.

The pediatrician is frequently called on to
answer the following questions:

a. Is a single convulsion of undertermined

O

etiology of sufficient evidence to make a
diagnosis of epilepsy?

b. Should a patient who has had only one con-
vulsion of undetermined etiology be given
prolonged therapy with anticonvulsant
drugs in the same manner as a patient who
has had many seizures?

c. Is much lost if treatment is delayed until
the patient has another seizure?

Our answers to these questions are as follows.
A patient who suffers with a seizure and in
whom a specific cause, such as hypoglycemia,
hypocalcemia, fever, and so forth, cannot be de-
termined should be regarded as having epilepsy
unless repeated examinations and the passage
of time prove it to be a manifestation of some
other disorder. This is true whether the electro-
encephalogram is normal or abnormal.

samuel livingston is assistant professor of pediat-
rics at Johns Hopkins University School of Medicine.

Paper presented at the annual meeting of the
North Dakota State Medical Association in Fargo,
May 28, 1957.

VVe believe that much is to be gained, in most
instances, by immediately instituting prolonged
therapy in patients who have had only one epi-
leptic seizure. Certainly, seizures are much less
apt to recur if the patient receives prolonged
therapy with anticonvulsant drugs.

The adverse emotional effect of a recurrence
of seizures is also an important factor which
should be considered. In the very young child,
this is'really not of consequence as far as the
patient is concerned, but it is extremely impor-
tant in the case of the older child. It is always
important to the parents, and we believe that it
outweighs the adverse emotional effect of daily
medication in an apparently healthy child.

The attitudes of the parents must be consid-
ered very seriously. Let us suppose that we see
a 5-year-old child who has had a major motor
epileptic seizure. The public today is verv “epi-
lepsy minded,” and the parents will undoubtedly
ask about the possibility of subsequent seizures.
The physician must tell the parents that there is
a chance that their child will experience a re-
currence of seizures. If the parents are told to
go home and return for treatment only if their
child has another seizure, they will obviously be
under great emotional stress. Many of our par-
ents who were given such instructions kept their
children under constant surveillance for years
thereafter. On the other hand, if the patient is
treated immediately after the initial convulsion
and the parents are told that the chances that
seizures will recur are much less if the child
continues to take the medication regularlv for a
prolonged period of time, both the parents and
the patient soon return to a normal life.

2. Selection of the drug of first choice for the
treatment of any case of epilepsy depends upon
the type of seizure. Some anticonvulsants are
more effective in controlling certain tvpes of
seizures. On the other hand, some drugs often
increase the frequency of some types of convul-
sions.

For example, phenobarbital and Dilantin are
particularly effective in the control of major
motor seizures but frequently accentuate petit

182

THE JOURNAL-LANCET

TABLE 1

DRUGS CURRENTLY IN USE FOR

CONTROL OF DIFFERENT TYPES OF EPILEPTIC SEIZURES ARRANGED
IN ORDER OF OUR PREFERENCE.

BASED ON RELATIVE EFFECTIVENESS, TOXICITY, AND COST

Major motor

Petit mal

Minor motor

Psychomotor

Phenobarbital0

Benzedrine

Phenobarbital0

Dilantin

(or Mebaral)

(or Dexedrine)
sulfate

(or Mebaral)

Dilantin

Paradione

Miltown
( Equanil )

Phenobarbital
(or Mebaral)

Mysoline

Tridione

Bromides

Benzedrine

( or Dexedrine )
sulfate

Bromides

Dimedione00

Benzedrine

(or Dexedrine)
sulfate

Mysoline

Peganone

Celontin

Celontin

Peganone

Gemonil

Diamox

Milontin

Celontin

Mesantoin

Milontin
Miltown
( Equanil )
Atabrine

Gemonil

Phenurone

Tridione

Mesantoin

Prenderol

"Mebaral is given to patients who manifest untoward reactions to phenobarbital.

00 At the time of this writing, Dimedione could he purchased only from Leo Pharmaceutical Products, Lovens Kemiske Fahrik, Brons-
kojvej, Copenhagen, Denmark.

mal spells. Tridione, on the other hand, is an
effective agent for petit mal spells but sometimes
precipitates major motor seizures or increases the
frequency of pre-existing major motor epilepsy.

Many drugs are now being used to treat the
various types of epileptic seizures. The drug of
first choice for any given case should be selected
on the basis of relative effectiveness, toxicitv, and
cost of the drug ( table 1 ) .

3. Treatment should begin with one drug.
Others should be prescribed only after it has
been determined that the maximum tolerated
dosage of the starting drug failed to produce a
satisfactory clinial response.

In patients who suffer relatively infrequent
seizures, the conventional starting dosage should
be prescribed initially. The dosage of this drug
should be increased, if necessary, until a satisfac-
tory control of seizures is attained or until the
limit of tolerance has been reached. In some in-
stances, a second drug may be necessary, but it
should not be prescribed until after it has been
determined that the maximum tolerated dosage
of the first drug failed to produce a satisfactory
clinical response. If the maximum tolerated dos-
age of the first drug fails to control the seizures
satisfactorily but does reduce the frequency or
severity of the seizures to some extent, it should
be continued at the same dosage along with the

second drug, and the dosage of the second drug
should be increased, as needed, to tolerance.
However, if the maximum tolerated dosage of
the first drug fails to help the patient in any
manner, it should he gradually withdrawn simul-
taneously with the administration of the second
drug. Occasionally, it may he necessary to pre-
scribe the maximum tolerated dosage of more
than two drugs in order to obtain a good con-
trol of seizures.

In patients who experience relatively frequent
and severe seizures, the average maximum dos-
age should be prescribed initially. This dosage
should be decreased or increased, if necessary,
depending upon the patient’s tolerance and the
frequency of seizures. Other drugs should be
added to the therapeutic regimen, if required, in
the same manner as heretofore mentioned.

The medication should be taken daily. It
should be given at times that do not interfere
with the patient’s routine activities, such as with
meals and at bedtime. In most instances, it is
advisable to prescribe the total dosage in equal
divided amounts throughout the day.

4. The therapeutic dosage of anticonvulsant
medication varies between patients. The proper
dosage for any given patient is that which con-
trols his seizures without producing untoward
reactions which interfere with his general well-

MAY 1958

183

being. Dosage should not be increased to the
point where the patient is so dvdl that he is more
incapacitated by the administration of the drug
than by the attacks themselves.

The goal in the treatment of epilepsy is to
attain a complete control of seizures. The drug
dosage necessary for complete control may, in
some patients, produce unpleasant reactions,
such as drowsiness, which are more of a handi-
cap than the seizures themselves. Some patients
may be better off leading a normal life between
occasional spells than living free of seizures in
a perpetual state of drug-induced drowsiness and
confusion. In instances of pronounced drowsi-
ness, it is advisable to administer daily dosages
of stimulating drugs, such as amphetamine sul-
fate, before reducing the drug dosage below the
level which controls seizures.

5. The medication should he taken daily , at
the same dosage which controlled the seizures,
for at least four years after the time of the last
conmdsion. If the four-year period of freedom
from seizures should coincide with the onset of
puberty, the medication should be continued
throughout the adolescent period. This is par-
ticularly important in girls.

6. The medication should be discontinued very
gradually. Following the four-year-period of
freedom from seizures, dosage should be reduced
gradually over a period of one to two years. It
is important to note that a sudden withdrawl of
anticonvulsant drugs, especially phenobarbital,
frequentlv causes recurrence of seizures or status
epilepticus. Dosage should be increased im-
mediately to the original level if attacks should
recur during the period of reduction.

7. Periodic physical and laboratory examina-
tions should be made on all patients receiving
certain drugs. Complete blood counts should be
made on all patients receiving such drugs as
Mesantoin, Tridione, and Paradione, which are
know to have an adverse effect on the hemato-
poietic system. These should be made before
the institution of therapy and at least at monthly
intervals thereafter. If no abnormalities occur
within twelve months, the interval between
counts may be extended. It is our policy to dis-
continue the use of the drug in patients in whom
the total white count drops below 3,500 or in

whom the percentage of neutrophils is markedly
reduced or whose platelet count drops below
125,000. The drug may be readministered when
the blood count returns to normal. In such cases,
however, blood counts should be made twice
a week for a month or so thereafter. The par-
ents or the patient should be instructed to re-
port immediately any sign or symptom of poss-
ible damage to the hematopoietic system, such
as fever, sore throat, easy bruising, bleeding
gums, petechiae, ecchymosis, epistaxis, or vaginal
bleeding.

Periodic urine examinations should be made
on patients receiving drugs which are known to
have had an adverse effect on the genitourinary
system, such as Tridione and Paradione.

Liver function tests should be performed on
patients receiving Phenurone before the institu-
tion of therapy and at regular intervals there-
after. The parents or the patient should be ad-
vised .fo report immediately to the physician the
appearance of jaundice, dark urine, general mal-
aise, fever, gastrointestinal upset, or any other
disturbance which may be indicative of a be-
ginning hepatitis. Phenurone should be em-
ployed with caution in any individual with a his-
tory of previous liver damage.

A drug should be discontinued immediately at
the first appearance of any tvpe of cutaneous
reaction. It is important that the patient be pro-
tected with some other type of drug when this
is done, as sudden withdrawl of a drug may
precipitate a recurrence of seizures or status
epilepticus. The same dosage of the drug may be
prescribed again to patients with the milder
types of rashes, such as the morbilliform, scarla-
tiniform or urticarial rashes, but only after the
rash has completely disappeared. It is inadvis-
able to continue use of the drug in patients in
whom purpuric rashes, exfoliative dermatitis,
or other serious skin reactions appear. The oc-
currence of the rash for the second time is also
a contraindication for the continued use of the
drug.

The data presented in this discussion were taken in
part from The Diagnosis and Treatment of Convulsive
Disorders in Children by Samuel Livingston. Springfield,
Illinois: Charles C Thomas, 1954.

184

THE JOURNAL-LANCET

Drug Synergism in the
Management of Arthritides

RALPH A. FORD, M.D., and
KENNETH RLANCHARD, M.D.

Belleville, New Jersey, and Cheyenne, Wyoming

It is a well-known and generally accepted ob-
servation that the concurrent administration
of two or more therapeutically related drugs may
be attended by a better clinical response than
can frequently be secured by either agent when
used alone in equivalent dosage. For many gen-
erations, this principle was the basis of the phy-
sician’s prescription, and, although a consider-
able degree of empiricism was then involved,
today, in numerous instances, the rationale of
drug combinations can be definitely established
by objective pharmacologic studies. As a rule,
two drugs of qualitatively identical or closely
similar actions produce effects which are purely
additive in character. On the other hand, two
drugs may cause similar physiologic responses,
although producing their action through entirely
different channels and on systems which are even
diametrically opposed in their functions. Under
these circumstances, the combined effect is not
necessarily additive but may follow a logarithmic
curve to which the term “potentiation” is fre-
quently applied.

The present study is concerned with the clini-
cal use of two popular and very frequently pre-
scribed antiarthritic preparations— Pabalate-Sod-
ium Free and Pabalate-HC. The principal in-
gredients of each of these preparations possess
antiarthritic and antirheumatic properties, ar I
a good deal is known not only of the site and
mode of action of each compound but also the
manner in which one may augment or modify
the other for greater therapeutic efficiency and
with fewer undesirable side reactions.

For more than seventy-five years, salicvlates
have been used for the treatment of arthritis and
other rheumatic disorders, and, although a con-
siderable measure of symptomatic relief could
be attributed to analgesia, the degree of thera-
peutic response could not be explained by this

Ralph a. ford is on the staff of Essex County Iso-
lation Hospital, Belleville, New Jersey, kenneth
blanchard is a specialist in pediatries with offices
in Cheyenne, Wyoming.

property alone. The salicylates have other im-
portant actions, which have been brought to light
only within recent years. Because of the neces-
sity of giving comparatively large doses in order
to obtain a satisfactory clinical response, the
incidence of undesirable effects is high and
symptoms of salicylism occur quite frequently
when aspirin or plain sodium salicylate are used.
Little evidence, however, suggests that these
toxic effects are related to the principal action of
salicylates which renders the drugs effective in
the treatment of rheumatic disorders. It seems
quite significant that mild Cushing’s syndrome
was reported by British investigators1 to have
occurred during intensive salicylate therapy, in-
dicating that the adrenal cortex had been stimu-
lated to overactivity or, at least, that the effect
of salicylates closely resembled the steroid hor-
mones of the adrenal cortex. A year later, van
Cauwenberge and Heusghem,2 of the University
of Liege, observed a pronounced increase in
urinarv reducing steroids after salicylate ther-
apy, but the 17-ketosteroid values were variable.
These observations have been confirmed by other
authors.3 The studies of Done and associates,4
of the University of Utah, are particularly in-
teresting in showing a marked elevation of plas-
ma 17-hydroxycorticosteroid in nonrheumatic
fever patients and in guinea pigs following sali-
cylic intoxication. In the presence of active
rheumatic fever, however, these investigators5
were unable to demonstrate a consistent effect of
salicylates upon plasma corticoid levels, although
greater fluctuations in values were encountered
than were usually found as a diurnal variant in
untreated patients.

It has come to be generally recognized that
the antiarthritic and antirheumatic action of
salicylates is mediated through the pituitary ad-
renal axis, producing effects which are practi-
cally indistinguishable from those resulting from
ACTH or from hydrocortisone. Albanase and co-
workers6 have called attention to some import-
ant nutritional characteristics of salicylates when
used in the treatment of children with active

MAY 1958

185

rheumatic fever. Their observations indicate that
the adrenal corticotropic action of salicylates,
as evidenced to some investigators by alterations
in the count of circulating eosinophils, does not
cause catabolic effects on the vitamin C or nitro-
gen stores of the human body.

A second component of the Pabalate formula-
tion is para-aminobenzoic acid which is available
either as the sodium or potassium salt. This
compound plays a very important role in metabo-
lism as the prosthetic moiety of certain enzyme
systems and is considered a member of the B-
eomplex vitamins. Aside from this nutritional
or metabolic effect, para-aminobenzoic acid ex-
hibits a pronounced antirheumatic action princi-
pally in the rheumatoid type of arthritis, al-
though the initial analgesic effect is less than that
produced by aspirin or sodium salicylate. It
seems quite logical that a combination of sali-
cylates and para-aminobenzoates, as represented
in Pabalate, should provide the additive thera-
peutic effect of both drugs, although the quanti-
ties of each ingredient would be below the toxic
threshold and, therefore, the combination would
occasion fewer adverse side reactions. For all
practical purposes, this would amount to an in-
crease in the therapeutic index for the combin-
ation, as contrasted with that for the ingredients
administered separately and in therapeutically
effective dosage. Because of the favorable re-
sponses of some collagen diseases to para-amino-
benzoic acid and, also, the inhibitory action of
the drug on hepatic inactivation of estrogens,
Wiesel and co-workers7-9 investigated the effects
of concurrent administration of para-aminoben-
zoic acid and cortisone in rheumatoid arthritis.
Their observations indicate a definite synergistic
effect and that the combined use of these com-
pounds permitted effective control of the clinical
manifestations of rheumatoid arthritis with much
smaller cortisone dosage. Using liver tissue from
rats as well as from human beings, Wiesel10 was
able to confirm by in vitro studies the original
concept that para-aminobenzoic acid interferes
markedly with the rapid reduction of unstable
conjugated systems of the cortisone molecule
while permitting more rapid degradation of the
side chain. A similar hepatic competitive action
has been demonstrated for salicylates toward the
inactivation of alpha-estradiol by retarding keto-
steroid conversion, and, presumably, this would
apply to other steroid hormones, including those
of the adrenal cortex.

What seems, therefore, to be a very plausible
explanation for the synergistic effect of salicylates
and para-aminobenzoates as related to the ad-
renal corticosteroids is that these drugs are not

only competitive in the liver toward their mutual
conjugation and inactivation, hut they jointly
compete with the 17-hvdroxy corticosteroids in
the hepatic inactivation processes.

On more or less empirical grounds, Dry and
associates,11 of the Mayo Clinic, were led to ad-
minister para-aminobenzoates and salicylates
concurrently in the treatment of rheumatic fever
and obtained such a dramatic response that
further studies on the mechanism of this svner-
gism were made. Determinations of plasma
salicylate levels indicated to these investigators
that the two compounds appeared to exert a re-
ciprocal effect in increasing their concentration
in the blood stream when given together orally.
It was suggested that competitive renal clearance
might be a factor in producing these elevated
plasma values.

Although ascorbic acid is contained in the
Pabalate formulation to the extent of 50 mg. per
tablet, >the role which this vitamin plays in the
physiology of adrenal cortex is not clearly under-
stood. The adrenal cortices seem to store ascor-
bic acid in exceptional quantities as compared
with other tissues, and the amount present is
often taken as a guide to the functional capacity
of the gland. Apparently, man and some animals
are unable to synthesize the vitamin from their
diets and must, therefore, depend upon receiving
the vitamin from exogenous sources. Notwith-
standing the apparent lack of clinical correlation
between arthritis and scurvy, it has been suggest-
ed that the vitamin may play some role in the
synthesis of the adrenocortical hormones. Deple-
tion of the stores of ascorbic acid may result
from intensive salicylate therapy,1213 stress, or
the use of pituitary adrenocorticotropic hormone
or cortisone and similarly acting steroids. Poliak
and Halperin14 and Schroeder15 feel that vita-
min C stores should he maintained when corti-
sone or ACTH is given.

The therapeutic effectiveness of Pabalate in
the treatment of rheumatic diseases and the
relative freedom from undesirable side reac-
tions have been reported by several authors.1017
Smith18 has shown that the pain relieving qualitv
of the combination was superior to sodium sali-
cylate in patients suffering from arthritis and
fibrositis and that the relief lasted longer. Un-
pleasant side reactions were not observed with
the combination, whereas toxic manifestations
were exhibited by 69, or 55.2 per cent, of 125
patients receiving sodium salicylate alone. The
degree of analgesia was, however, somewhat less
pronounced in the osteoarthritie group than in
the rheumatoid type. In a study of the effect of
certain antiartlnitic drugs. O'Connell and associ-

186

THE JOURNAL-LANCET

ates19 reported that the combination of para-
aminobenzoic acid and salicylic acid ( Pabalate )
caused a significant increase in the eosinophil re-
sponse to ACTH, whereas neither sodium para-
aminobenzoate nor sodium salicylate alone in a
daily dosage of 60 to 90 mg. per kilogram of
body weight altered this eosinophil response.

CLINICAL MATERIAL AND METHODS

Because of the many individual variables en-
countered when attempting to evaluate arthritic
therapy in ambulatory patients, this study was
limited to a series of 60 patients who were hos-
pitalized and under continuous medical super-
vision. Environmental and dietary factors, physi-
cal therapy, and other considerations were rea-
sonably uniform, although the nature and sever-
ity of the symptoms and the duration of the dis-
ease varied widely. Thirty-five of the patients
were classified as having the degenerative form
of arthritis, such as osteoarthritis, senescent or
hypertrophic arthritis, or arthritis deformans.
About half of the remainder were classified as
exhibiting some form of degenerative arthritis,
and the rest were definitely placed in the rheu-
matoid category. A complete record was main-
tained for each patient from the time of admis-
sion until discharge from the hospital. Detailed
information about the date and nature of the
onset of the disease, estimations of the severity
of pain and discomfort, limitation of motion, de-
formities, edema, and pain in joints or muscles
after rest and activity were carefully recorded.
Numerous periodic fluctuations in the severity
of symptoms made an accurate evaluation of the
results quite difficult or impossible. In order,
however, to create some practical degree of uni-
formity in the evaluation of antiarthritic agents,
the New York Rheumatism Association, in 1949, 20
proposed a system of classification of arthritic
patients which could be conveniently utilized as
a guide in evaluating the progress of treatment
without resorting to laboratory tests or elaborate
objective measures. This system has been fol-
lowed in reporting the results of this investiga-
tion.

On admission to the hospital, the patient was
subjected to a thorough physical examination to
determine the nature and degree of disability.
Quantitative evaluation of the range of motion
was recorded by means of a goniometer, and a
dynamometer was used to estimate strength of
muscles of the forearm, wrist, and hands. These
tests were repeated at frequent intervals. In
addition, routine roentgenograms of the chest,
spine, and affected joints were made, and electro-
cardiographic studies were conducted whenever

cardiac involvement was suspected. Blood and
urine specimens were obtained at frequent in-
tervals for the usual chemical and histologic ex-
aminations, and erythrocyte sedimentation rate
determinations were made every two or three
weeks during the period of hospitalization.

The basic and palliative treatment of the
patients, regardless of rheumatic classification,
consisted of the usual dietary measures with
additional vitamins or tonics when necessary.
A low-salt diet was prescribed for those who
were obese or when there was evidence of
edema, sodium retention, or cardiovascular renal
disease. Many of the patients received physio-
therapy as an important part of their treatment
five days of each week, depending upon individ-
ual needs. Drug therapy in all cases consisted
of Pabalate-Sodium Free or Pabalate-HC (same
formulation but with the addition of 2.5 mg. of
hydrocortisone). The latter preparation was re-
stricted for use in the more severely afflicted
rheumatoid patients when the disease was not
complicated by peptic ulcer, pulmonary tubercu-
losis, diabetes mellitus, psychoses, or other con-
ditions which enjoined caution in the use of ad-
renocorticosteroids or ACTH. The usual dosage
of Pabalate-Sodium Free consisted of 4 tablets
administered 4 times daily, although it was felt
that many patients could have been effectively
treated with a much lower dosage. The initial
dose of Pabalate-HC was 2 tablets given 3 times
daily and gradually increased as necessary to
gain a satisfactory remission of symptoms. After
this response, the dosage was gradually reduced
to avoid rebound effects, which are often re-
ported when the dosage of cortisone or hydro-
cortisone is too rapidly reduced. The results ob-
served in the treatment of the 60 cases of arthritis
based upon relief of symptoms and restoration of
functional capacity are summarized in table 1.

Of considerable interest was the observation
that the clinical response to the drug combina-
tion therapy was very closely related to the dur-
ation of the disease. This correlation is shown
in table 2.

As a matter of convenience, the 60 patients
comprising this study were classified as having
(1) rheumatoid arthritis or (2) degenerative
joint disease, and it seems quite important to
consider the efficacy of treatment for each group
as a separate entity. The great majority of the
rheumatoid arthritic patients showed consider-
able diminution of stiffness, easing of joint pain,
and a distinct feeling of well-being, usually with-
in four to five days after starting therapy. The
most dramatic results were observed in patients
who had had arthritis for a short time. Joint

MAY 1958

187

TABLE 1

EFFECT OF PABALATE THERAPY UPON CLASSIFICATION OF ARTHRITIC PATIENTS
ACCORDING TO FUNCTIONAL CAPACITY

Class

Functional basis

Number of patients
in each class

On admission At discharge

Remarks

I

Mild: Ability to carry on usual duties
without discomfort.

6

24

18 patients showed superior improve-
ment to enter Class I.

II

Moderate: Ability to perform duties
despite discomfort or limited motion

33

26

15 remaining Class II patients and 11
transferred from Class III.

in one or more joints.

III

Severe: Activity limited to few, if any,
of the duties of occupation or self-care.

18

7

7 patients failed to show sufficient
improvement for reclassification.

IV

Incapacitated: Bedridden or confined
to wheelchair; little or no self-care.

3

3

Disease too far advanced to show ap-
preciable improvement.

TABLE 2

EFFECT OF DURATION OF ARTHRITIS UPON PERIOD Of'hOSPITALIZATION AND TREATMENT

Duration
of disease

Number
of patients

Per cent
of series

Period of
treatment

Number
of patients

Per cent
of series

1 to 5 yr.

4

6.5%

to 3 mo.

16

26.0%

5 to 10 yr.

20

34.0%

3 to 6 mo.

21

35.0%

10 to 20 yr.

24

40.0%

6 mo. to 1 yr.

19

32.5%

Over 20 yr.

12

19.5%

Over 1 yr.

4

6.5%

changes, such as tenderness and swelling, pain,
and limited motion, were invariably followed by
diminished arthralgia and increased range of
motion, as indicated by lack of unusual discom-
fort as well as by goniometric readings. In the
degenerative, or osteoarthritic, group of patients,
which comprised approximately 50 per cent of
the series, Pabalate was given in doses sufficient
to produce a satisfactory degree of analgesia
without causing undesirable side reactions. There
was no evidence of nausea, tinnitus, or other
signs of salicylism. Blood salicylate levels were
not determined because the wide range of values
reported by different investigators made it diffi-
cult to correlate the plasma levels of salicylates
with the degree of clinical response. Also, there
is little reason to assume that the maximum de-
gree of relief is chronologically coincident with
the peak plasma salicylic level. In many cases, the
medication could have been reduced after ob-
taining the desired relief of symptoms, but pa-
tients were advised to continue treatment at
home or to increase the dosage if severe symp-
toms and pain recurred. On two separate occa-
sions covering one week each, aspirin in equiva-
lent dosage was substituted for Pabalate, with

the result that the majority of patients com-
plained of increased joint pain and, frequently,
of ringing in the ears and gastric upsets. While
there is little doubt as to the analgesic efficacy
of acetylsalicylic acid, particularly in acute epi-
sodes of pain where temporarily high salicylate
levels are desired, evidence seems to indicate
that the concurrent administration of para-amino-
benzoic and salicylic acid produces a more uni-
formly sustained level for prolonged analgesia
and, therefore, is superior to aspirin in the treat-
ment of chronic rheumatic disorders.

CONCLUSIONS

1. Combinations of para-aminobenzoic and
salicylic acid, as the potassium salts, with ascor-
bic acid ( Pabalate-Sodium Free) exhibit a pro-
nounced antirheumatic effect in the majority of
patients with degenerative joint diseases, as man-
ifested by decreased pain and by increased range
of motion of the affected joints.

2. This combination of drugs is of special
value in rheumatoid arthritis when treatment is
established before the occurrence of fibrous or
bony ankylosis. In severe rheumatoid arthritis,
the same formulation with the addition of hydro- Ij

188

THE JOURNAL-LANCET

cortisone (Pabalate-HC ) is often dramatically
effective with few undesirable side effects.

3. The observations reported in this clinical
study are confirmatory of the synergistic relation-

ship between salicylates, para-aminobenzoates,
and the adrenal corticoids.

4. Clinical results are most favorable in ar-
thritis of recent origin.

REFERENCES

1. Cochran, J. B., Watson, R. D., and Reid, J.: Mild Cush-

ing’s syndrome due to aspirin. Brit. M. J. 2:1411, 1950.

2. van Cauwenberge, E. H., and Heusghem, C.: Acetyl-salicylic
acid and urinarv excretion of adrenocortical steroids. Lancet
1:771, 1951.

3. Bertolani, F., Lorenzini, B., and Bonati, B.: Lancet 1:

54, 1951.

4. Done, A. K., Ely, R. S., and Kelley, V. C.: Studies of 17-
hydroxycorticosteroids; blood levels in salicylate intoxication.
J.' Pediat. 44:153, 1954.

5. Done, A. K., Ely, R. S., and Kelley, V. C.: Response of

plasma 1 7-hydro xycorticosteroids to salicylate administration
in normal human subjects. Metabolism 4:129, 1955.

6. Albanese, A. A., Higgons, R. A., Avery, W. G., Dilallo,
R.: Effect of salicylates on vitamin C stores of rheumatic
fever patients. New York J. Med. 55:1167, 1955.

7. Wiesel, L. L., Barritt, A. S., and Stumpe, W. M.: Syner-
gistic action of para-aminobenzoic acid and cortisone in treat-
ment of rheumatoid arthritis. Am. J. M. Sc. 222:243, 1951.

8. Wiesel, L. L., Barritt, A. S., and Stumpe, W. M.: Brook-
lyn Hosp. J. 8:148, 1950.

9. Wiesel, L. L., Barritt, A. S.: Long term treatment of

rheumatoid arthritis with para-aminobenzoic acid and corti-
sone acetate. Am. J. M. Sc. 227:74, 1954.

10. Wiesel, L. L.: Effect of para-aminobenzoic acid on metab-
olism of cortisone in liver tissue. Am. J. M. Sc. 227:80, 1954.

11. Dry, T. J., Butt, H. R., and Scheifley, C. H.: Effect of oral
administration of para-aminobenzoic acid on concentration of

salicylates in blood. Proc. Staff Meet., Mayo Clin. 21:497,
1946; correction 22:55, 1947.

12. van Cauwenberge, H.: Relation of salicylate action to pitui-
tary gland; observations in rats. Lancet 2:374, 1951.

13. Blanchard, K. C., Dearborn, E. H., Maren, T. H., and
Marshall, E. K.: Stimulation of anterior pituitary by certain
cinchoninic acid derivatives. Bull. Johns Hopkins Hosp. 86:
83, 1950.

14. Pollak, H., and Halperin, S. L.: Therapeutic nutrition.

Pub. No. 234, Nat. lb s. Council, 1952.

15. Schroeder, H.: Vitamin C-Mangel durch Stress bzu. nach

ACTH- und Cortisondarreichung. Munchen Med. Wchnschr.
94:339, 1952.

16. Barden, F. W., Hill, P. S., and Cuneo, K. J.. J. Maine
M. A. 46:99, 1955.

17. Cass, L. J., Frederik, W. S., and Cohen, J. D.: Para-

aminobenzoic acid and salicylates in treatment of arthritis.
Journal-Lancet 76:42, 1956.

18. Smith, R. T.: Treatment of rheumatoid arthritis and other

rheumatic conditions with salicylate and para-aminobenzoic
acid. Journal-Lancet 70:192, 1950.

19. O’Connell, P. A., Roy, A., and Massell, B. F.: Effect of
salicylate and para-aminobenzoate on eosinophil response to
ACTH. Am. J. M. Sc. 229:150, 1955.

20. Steinbrocker, O., Traeger, C. H., and Batterman, R. C.:
Therapeutic criteria in rheumatoid arthritis. J.A.M.A. 140:
659, 1949.

Unilateral numbness and weakness, especially of the face, tongue, arm, or
leg, may precede the pain of migraine rather than visual aura. Hemiplegic mi-
graine is probably caused bv spasm of the branches of the internal carotid
artery. Two types can be distinguished.

Minor hemiplegic migraine occurs on either side and the paresthesia dis-
appears after the pain begins. The common visual aura may also occur at
times in the same patient. Other family members probably have migraine,
though not necessarily the same kind.

Major hemiplegic migraine often occurs exclusively on one side. The aura
is prolonged and either persists or increases after onset of pain. The cerebral
disturbance is evidently more widespread, as confusion, drowsiness, coma,
or bilateral motor signs are noted. These patients seldom have any other type
of migraine. Usually, the same kind of attack has appeared in several members
of the family for two or three generations.

Tumor or cerebral angioma must be considered in the differential diagnosis
of migraine headache, especially the hemiplegic type, when attacks are exclu-
sively unilateral. If physical findings are inconclusive, carotid arteriography
may be necessary.

R. T. Ross, M.D., Winnipeg. Canad. M.A.J. 78:10-16, 1958.

MAY 1958

189

The Mechanism of Parathyroid Function

W. F. NEUMAN, Ph.D.

Rochester, New York

To begin, it is important to review briefly
parathyroid function as it was pictured in
the late forties and early fifties. Based on the pio-
neering work of Collip, MacCallum, and Vogt-
lin, the principal effects of parathyroid secre-
tions were well-established. In excess, these se-
cretions cause hypercalcemia, hypophosphat-
emia, increased phosphate excretion, and a char-
acteristic fibrotic change in the bones. This
change, osteitis fibrosa, is suggestive of a very
active erosion and remineralization. If the hy-
percalcemia has been chronic in nature, renal
dysfunction and renal calcifications are frequent-
ly seen.

In the absence of the parathyroid glands,
prettv much the opposite picture is observed.
A low-serum calcium and a high-serum phos-
phate are characteristic. The bones appear dense
and highly mineralized. The classical, clinical
picture is, of course, a convulsive tetany presum-
ably caused by the low-serum calcium.

This rather confusing, though simple set of
variations, was first explained in an over-all
concept by Dr. Fuller Albright and was elab-
orated in detail in bis now classical book written
in collaboration with Dr. Edward Reifenstein,
“Parathyroid Glands and Metabolic Bone Dis-
ease.” According to their view, parathyroid hor-
mone first induced a large outpouring of phos-
phate in the urine through a direct renal action.
On the presumption that the serum is approxi-
mately saturated with bone mineral and that any
fall in the calcium phosphorus product of serum
causes the bone mineral to dissolve, this outpour-
ing of phosphate in the urine results in a dissolu-
tion of bone mineral with a transfer of calcium
and phosphorus to the blood. Because the mo-
bilized calcium does not go out in the urine, it
accumulates in the serum. According to this
view, the over-all parathyroid effect is thus a
renal action followed by a more or less passive
response in bone.

WILLIAM F. NEUMAN is CLSSOCUlte pwfeSSOr of pluil-
macology and biochemistry at the University of
Rochester Scljool of Medicine and Dentistry , Roches-
ter, New York.

This paper is The Journal-Lancet Lecture
which was presented December 6 , 1957, at the
University of Minnesota.

Unfortunately for the Albright concept, two
sets of experiments have been reported which
conclusively show the bone action of the hor-
mone is a direct and important event. Barnicot,
in England,1 and Chang,2 in Chicago, have trans-
planted bits of parathyroid tissue to bone. Im-
mediately adjacent to these grafts, the bone has
been observed to resorb. Other transplanted tis-
sues do not bring about this resorption. Also im-
portant was the work of Stewart and Bowen,2
Talmage and associates,4 and Monahan and
Freeman/1 who were able to demonstrate a full
hypercalcemic effect in animals whose kidneys
had been removed. Clearly, then, the action on
bone is a primary one.

Let us not presume, however, that Dr. Albright
was unaware of the rather fragile experimental
basis on which his over-all scheme had been
built. In the very beginning of his book, he
spends many pages attempting to determine
whether serum is saturated or undersaturated
with respect to bone mineral. He kept reaching
such conclusions as the following: “Unfortu-
natelv, both these calculations leave the serum
very much supersaturated which is unlikely.”
And again: “However, if one calculates the solu-
bility products from the calcium and inorganic
phosphoruses of spinal fluids, one still comes out
with supersaturation.” He refers to the blood-
bone equilibrium in the following terms: “In
spite of the fact that the chemists and the physi-
cists have not come to a final conclusion as to
what equilibrium is involved, for the clinician,
the important inference is that the body fluids
are either saturated or at a constant degree of
supersaturation or undersaturaticn in respect to
some salt of calcium and phosphate, so that in
the absence of any fluctuation in the pH, a rise
in the calcium ion will lead to a fall in the
phosphate ion and vice versa."

Such an uncertain situation may be good
enough for the clinician in some cases, but it is
not adequate for the biochemist, particularly
if he wants to build on the concept. The rea-
son, of course, that Albright could not draw
from the chemists a final conclusion regarding
solubilities is that arguments were still being
waged in the literature concerning the nature of
the bone salt itself, and these arguments con-

190

THE JOURNAL-LANCET

tinued into the early fifties. Just as important
was the fact that two schools of “solubility
thought” were well represented — one school
holding that serum was highly supersaturated
and the other claiming that the serum was high-
ly undersaturated — while a middle group found
it difficult to believe that serum could be in any-
thing but a moment to moment equilibrium with
bone, and, therefore, was just saturated with
bone mineral. As we shall see, all groups were
correct; serum is both supersaturated, saturated,
and undersaturated all at the same time.

The present storv begins, then, with experi-
ments attempting to establish the nature of the
solid phase and its solubility. A number of re-
ports appeared in the literature suggesting what
the bone salt might be. For many years, it had
been recognized that much of the bone mineral
exhibits the lattice structure, as shown by x-ray
diffraction, characteristic of hydroxy apatite. But,
early suggestions of mixtures of salts kept at-
tracting new supporters. For example, in the
early fifties, Dallemagne and Cartier'5 in Bel-
gium, considered bone mineral to be a mixture
of calcium carbonate and magensium carbonate
and “fl-tricalcium phosphate.” Secondary cal-
cium phosphate, CaHP04, has also been promi-
nently mentioned as a component salt.

Now, physical chemistry tells us that crystal-
line salt dissolves unless the solution with which
it is in contact is just saturated. Can serum be
just saturated with respect to several salts simul-
taneously? Such a coincidence seems highly im-
probable. To resolve these questions, we must
consider the actual, effective concentration or
activity of calcium, of phosphate, and of carbo-
nate in normal human serum. This will permit
us to calculate solubility products accurately.
Then we will know whether there is merit to
these suggestions of mixtures.

The distribution of calcium in normal serum
is given in table 1. These are recent calcula-
tions7 using activity coefficients and the latest
ultrafiltration data of Toribara and associates.8
As the table clearly shows, approximately 65
per cent of the calcium is freely diffusible, and
35 per cent is bound to protein. Of the freely
diffusible part, only a small fraction is bound
in the form of complexes. These are the citrate
complex, the bicarbonate complex, and the phos-
phate complex. The net result is: the effective
concentration of calcium ion, in terms of activi-
ties, is about 0.5 x 10-3. It is interesting that these
calculations are in excellent agreement with the
early, classical work of McLean and Hastings.9
Recently, Howard’s laboratory, using a biologic
end point, also came to this same figure10 of

1.3 mm. ionic calcium — an activity of 0.5 x 10-3.

Phosphate, as far as we now know, is all free
and diffusible, and we have only to distinguish
between its various ionic forms. There is prac-
tically no tertiary phosphate ion in serum. For
our interest, secondary phosphate is the impor-
tant ion and, as seen in table 2, the effective con-
centration — the activity — of secondary phos-
phate ion is about 0.2 x 10-3. This figure multi-
plied by the calcium activity determined pre-
viously gives us a product of Ca++ x HP04= of
1 x 10-7 in normal adult human serum. We
shall use this expression abbreviated to Ca x P
throughout our discussion. Experience has shown
that this simple ion product is the best measure
of saturation of both serum and of inorganic
solutions in the region of near neutrality.11

Now, we must dispose of the suggestions of
the various mixtures of salts. Using the thermo-
dynamic concentrations, one can calculate that
serum is undersaturated with respect to calcium
carbonate. Such a material cannot form. If it
formed, it would dissolve. Similar calculations
can be made for magnesium carbonate and sec-
ondary calcium phosphate. Serum is less than
half saturated with respect to these salts. There
is further, more definitive evidence against the
occurrence of CaHP04. Data from the litera-
ture given in figure 1 illustrate what happens to
secondary calcium phosphate at physiologic pH.
Secondary calcium phosphate has a theoretic
mol ratio, calcium to phosphorus, of 1. As the

TABLE 1

DISTRIBUTION OF IONIC FORMS OF CALCIUM IN SERUM

Calcium fraction

raM.

Total

2.50

Protein-bound

.82

Soluble Complexes

,30

Ionic0

1.33

“Expressed as ion activity,

[ ( 1 .33 x lO"1 ) x 0,36] or 0.5x10 '.

TABLE 2

DISTRIBUTION OF IONIC FORMS OF INORGANIC
PHOSPHATE IN SERUM

Ionic fraction

mM.

Total

1

H2PO“

0.19

HPOr^

0.81“

PO,=

8xl0-5

“Expressed as ion activity.

[(81.x 10-') x 0.23] or :

2x 10 b

MAY 1958

191

ifi

X 12
Q.

« 1.0

8 0.8

pH 6.18

•O—

20 40 60

^ f-

1 1.

15 18

pH 7.4

AFTER

12

HOURS

MIXING

L

24 ' '10

— o — — o —

Fig. 1. Spontaneous conversion of secondary calcium
phosphate (Ca/P=l) to hydroxy apatite (Ca/P=1.66)
at physiologic pH. Taken from.11

figure shows, on standing, this material, though
it forms initially, is unstable and hydrolyzes
spontaneously to give the theoretic ratio of hy-
droxy apatite a mol ratio of 1.6. This chemical
finding was confirmed by an x-ray diffraction
analysis of the solid phase. Having discovered
for ourselves this remarkable event, we subse-
quently found that very early work by Shear and
Kramer12 had already demonstrated the insta-
bility of secondary calcium phosphate under
physiologic conditions. Some time later, Hodge
also demonstrated13 that, above pH 6.2, hydroxy
apatite is the only stable form. We may con-
clude, then, that bone mineral is not a mixture
of salts but, rather, represents a single mineral
phase — that of hvdroxy apatite: Caln(P04),;
( OH )2.

Hydroxy apatite is derived from the Greek
term meaning “to deceive.” This it has done for
many, many years. It is a miserable material
for study. The crystals are always very, very
tiny, of colloidal size, and present a tremendous
surface area of 100 to 200 square meters per
gram. Most substances in a macrocrystalline state
do not permit substitution of their constituent
ions because any lattice is a very rigorous-space-
charge structure. At the crystal surface, how-
ever, these requirements of space and charge
are much less rigorous. Because many of the
ions in hydroxy apatite salt reside in surface
positions, a wide variety of ion substitutions can
occur, and the composition of hydroxy apatite
mirrors the composition of its fluid environ-
ment.7 If the environment contains sodium, so
does the solid phase. If it contains carbonate,
so does the solid phase, and so on. As a result
of this extensive ion-exchange process, we find

Fig. 2. Point of spontaneous precipitation of calcium
phosphate as function of pH. Each point was determined
by mixing a series of solutions of graded contents of cal-
cium and phosphate to find the minimum product
( Ca x P ) which would cause precipitation in a ten-day
period of observation. Taken from.11

that bone mineral is not a pure hydroxy apatite
by any means. Rather, it contains many of the
ions found in the extracellular fluids: sodium,
carbonate, citrate, magnesium, and traces of flu-
oride. We know from well-established physico-
chemical theory that a substance which exhibits
variable composition cannot exhibit a fixed solu-
bility. If the surface composition varies, the es-
caping tendencies of the ions must vary. There-
fore, the solubility of bone mineral and of hy-
droxy apatite preparations cannot be defined ex-
cept in terms of the solution and the solid in-
volved in the equilibrium.

In the absence of a solid phase, hydroxy apa-
tite itself cannot form directly. This would in-
volve a collision of 16 to 18 ions all of the cor-
rect energies. On a statistical basis, this is im-
possible. We find, therefore, the only salt which
can form directlv in solutions is secondary cal-
cium phosphate. This involves a collision of
only 2 ions. As a result, the stability of solutions
in the absence of a solid phase is governed by
the solubility product of secondary calcium phos-
phate and, under most circumstances, some de-
gree of supersaturation is required to initiate
precipitation. These data11 are illustrated in
figure 2. Here we see that precipitation occurs
onlv at activity products higher than 3, and nor-
mal serum is onlv one-third of this precipitation
value. Therefore, we can conclude that, in the
absence of a solid phase, serum is highly under-
saturated.

192

THE JOURNAL-LANCET

TABLE 3

SUMMARY OF SOLUBILITY INFORMATION

9

10 (aCa++ * a HPOt ~ ^

Required for precipitation

2 to 5

Given on dissolution

0.001 to 0.5

Observed in serum

0.5 to 2

However, in the presence of a solid phase, at
physiologic pH, hydroxy apatite is the only
stable solid phase, and, further, all investigators
agree that hydroxy apatite has never dissolved
to give products equal to those found in normal
serum. We can conclude that in the presence of
a solid phase, serum is normally supersaturated.
This same conclusion was reached very recently
by Dr. Nordin, an Englishman, working at Co-
lumbia.14 The summary of this situation is illus-
trated in table 3, where we see that the product
required for precipitation is between 2 and 5.
That given on the dissolution of apatite is quite
variable hut never exceeds 0.5 under physiologic
conditions as defined by serum. Yet, we observe
products in nature ranging from .5 to 2, human
serum averaging 1. So, serum is both supersatu-
rated and undersaturated, depending on whether
or not a solid phase is present.

But, in the animal, a solid phase is always
present! We can, therefore, presume that some
kind of a discrepancy exists. Serum cannot cor-
respond to fluid which is in contact with bone
mineral. This may seem confusing, but the ex-
planation is really quite simple. This is illus-
trated in figure 3. 15 A given product of Ca x P
can be supersaturated, saturated, or undersatu-
rated, depending on the concentrations of the
different ions in the surrounding fluid. Here,
for example, the solubility curve is shown as it
varies with the citrate concentration. With low
concentrations of citrate, the bone mineral is
quite insoluble, hut at high concentrations of
citrate, it is quite soluble. As seen in figure 4,
a fixed Ca x P, such as that of normal serum, can
be supersaturated at the citrate concentration of
serum. But, if bone fluids were to have a higher
citrate concentration, this same Ca x P product
could be in equilibrium. We might substitute
on the abscissa pH for citrate. At low pH, bone
mineral is much more soluble than it is at high
pH. If, locally, the pH in bone were low, then
the product Ca x P seen in normal serum would
be perfectly reasonable as an equilibrium value.
We must, then, presume that the composition
of fluid bathing the mineral crystals is different

Fig. 3. Effect of citrate ion on solubility of bone salt (hy-
droxy apatite) at pH 7.4, ^ = 0.16. Solubility is expressed
as the thermodynamic product, a Ca++ * a HPCh = mul-
tiplied by 10‘7; thus, the range is from 3 x 1 O'7 to 9 x 107.
Taken from.7

NORMAL

SERUM

Fig. 4. Relation between the degree of serum’s satura-
tion with respect to bone mineral and its content of ci-
trate ion. See text for explanation. Taken from.'

from that of normal serum. It is either higher
in citrate, lower in pH, or different in some other
ion-concentration. This brings us to our major
postulate of cellularly induced ion-gradients. If
the bone cells maintain a special composition of
the bone fluid, that is, a pH lower than that
found in serum or a citrate concentration higher
than serum, we have resolved our solubility di-
lemma.

Let us digress for a moment to examine the
theoretic basis at a molecular level for the phe-
nomenon of a “medium-determined solubility.”

The following is the three-step derivation for
the solubility product, or KSp:

MAY 1958

193

L MA solid « — * tMAl solution (A)

by convention, the activity of any pure solid is
considered constant and equal to unity. Since

a is constant, rtAI4 = K. (B)

MA MA

But MA dissociates thus:

2. [MA] « — » [M+] + [A"] (C)

from which mass law gives us:

3. K = a w+ * fl *-/« MA or con'hining (B)
and (C), K1 = Kgp = a M+ * «A_

From this derivation, it is easily seen that solu-
bility produet principle holds only if the activity
of the solid phase is constant.

Turning now to exchange systems, the phys-
ical chemist has found that mass law again pro-
vides a useful derivation:

For the reaction, Na+ + HR — > NaR -f- H+
where R represents the resin or exchanger, we
may write

flNa+ ' aHR _ aNa+ mol fraction HR

a h+ 'rtNaR a H+ rnol fraction NaR

However, it has been found experimentally that
this relation breaks down if more than a few per
cent of the hydrogen positions have been dis-
placed bv sodium ions. When all hydrogens are
surrounded by other hydrogens, the escaping
tendency is a fixed quantity. As sodium ions
begin to substitute randomly, the escaping ten-
dency of the remaining hydrogens is altered.

From this experience, it is easily seen that the
activity of a solid is a constant only if relatively
unsubstituted.

Bone mineral is a highly substituted exchanger,
and its activity is, therefore, not a constant and
it cannot exhibit a KSp

The following steps of logic are:

1. Solubility depends on the activity of the
solid phase.

2. The activity of a solid exchanger depends
upon its degree of substitution.

3. The degree of substitution of a solid ex-
changer depends upon the composition of the
medium.

4. Therefore, solubility of a solid exchanger
depends upon the composition of the medium.

Since bone mineral, when added to serum,
causes a precipitation, it follows that the fluid
bathing bone must differ in its composition from
serum.

We have already stated that the crystal sur-
face permits ion substitutions not possible in the
lattice interior. Armstrong and Singer10 have
shown in an elegant fashion that citrate ions
enter the solid phase by replacing surface phos-
phate groups. As a result of this displacement,
the “citrated” surface exhibits a greater tendency
to lose its constituent ions, and the activity of
the solid phase is increased. We have obtained
similar results with other ions. Carbonate, for
example, displaces phosphate groups17 and in-
creases solubility.18 Hydrogen ions displace cal-
cium ions from the surface, and this too increases
the activity of the solid phase — its solubility.
This is an effect on the solid phase, a change in
thermodynamic properties of the crystal surface.
It is not chelation of calcium by citrate, or is it
a change in the ionization of phosphate by hy-
drogen ion.

This* resolution of the solubility dilemma is
the heart of the present story and, perhaps, war-
rants a restatement in slightly different terms.
We know from well-established results that the
Ksp of secondary calcium phosphate represents

a ceiling, the limit to the stability or solubility
of any aqueous calcium phosphate system. We
know too that the Ca x P given on dissolution
of hydroxy apatite preparations can be almost
anything, depending on the composition of the
fluid, here represented as X and signifying a
number of ions, carbonate citrate, pH and so
forth.

Turning now to the situation in the animal,
we find that serum, naturally enough, is well
below the point of spontaneous precipitation,
and, because of the rapid interchange of ions
between the circulation and the bones, it seems
only reasonable that the product Ca x P is the
same in bone as it is in the circulation.

The conditions in serum, again represented by
X, will not support such a high product if the
solid phase is present. Serum is supersaturated,
and this fact has been repeatedly shown by
many people.

What we propose is that local conditions, X,
in bone differ from those found in serum. The
pH is lower, the citrate concentration higher,
or some such local difference is the reason the
solid phase supports such a high Ca x P in serum.

Going back to the older views, those who at-
tempted precipitation experiments found blood
to be undersaturated. They were correct! Those
who performed dissolution experiments with the
solid phase under blood conditions found blood
to be supersaturated. They too were correct!
Finallv, those who reasoned that there could

194

THE JOURNAL-LANCET

hardly exist large concentration differences in
calcium and phosphate between bone fluids and
other extracellular fluids and that the bone and
blood were in an equilibrium were probably also
correct, but the equilibrium must be regarded
as dynamic and under cellular control.

We have been forced, then, to conclude that
the bone cells produce local high concentrations
of some surface active ion, such as hydrogen or
citrate. The question was: How can this pos-
tulated phenomenon be demonstrated?

We decided that to demonstrate pH in bone
accurately enough to satisfy ourselves and others
would be a problem fraught with technical dif-
ficulty. We, therefore, attempted to find whether
a gradient in citrate ion exists, whether the bone
cells maintain the crystals in an environment
rich in citrate.

We considered the problem of demonstrating
a gradient as essentially a problem in arterio-
venous differences. If there were a large citrate
gradient between bone and blood, the venous
flow from the bone shoidd be high in citrate,
higher than the arterial supply.

Unfortunately, no convenient veins are de-
rived exclusively from the bone circulation which
can be cannulated. We, therefore, compromised
and merely drilled a small hole into the spon-
giosa of the femur of the dog. This hole was
cannulated with small polyethylene tubing and
the dog, having been given anticoagulants, pro-
duced a nice flow of blood from the hole in the
spongiosa. Obviously, the blood which was ob-
tained from the hole was derived, in part, from
arterioles, in part, from venules coming from
bone and, in part, from venules collecting the
circulation derived from marrow. In order to
determine how much venous blood from bone
was contributing to the collected sample, stron-
tium89 was administered to the animal. Sr89
goes exclusively to bone and is, for practical
puq^oses, completely cleared from the blood in
a single pass. Therefore, the difference between
the arterial level of Sr89 and the Sr89 level in
the first collected blood gave an approximate
percentage of the sample which was derived
from the venous outflow of bone. A typical set
of data are given in figure 5, which show the
difference between the arterial level of stron-
tium and the level of strontium in the blood
derived from the hole. In this instance, there
were two different holes, one drilled directly
into the marrow cavity and one into the spon-
giosa. As expected, the blood from marrow had
a smaller contribution from bone areas than did
that derived from the spongiosa. Interestingly
enough, the citrate content of these various

specimens followed the same pattern, that is,
the sample having the largest venous contribu-
tion from bone had the highest citrate level —
higher than the arterial supply.

We have studied the citrate levels in a great
many dogs. In experiments on 9 normal ani-
mals, the average arterial citrate level was 3-mg.
per cent and that observed in the collected sam-
ples from the hole in the bone was 3.5-mg. per
cent, giving a gradient of 0.5-mg. per cent. The
average early strontium clearance in these ex-
periments was 20 per cent. From these data
may be calculated a rough estimate of the actual
level of citrate in the true venous outflow from
bone, 3 -|- ( 0.5 x —{}) = 5.5. This gives an esti-
mate of about 5.5-mg. per cent in venous blood
from bone, or, put another way, the level of
citrate in bone is apparently about twice that
in the general circulation. Presumably, this is
derived from the bone cells. Eight of the 9 nor-
mal animals studied showed easily detectable
gradients, giving a statistically significant differ-
ence, a p value of less than 0.01.

This seems like a reasonable confirmation of
the postulate that the fluid bathing the bone
crystals differs somewhat in its composition from
that seen in serum, and it differs with respect to
a very important ion — citrate.

The following questions immediately arise:
If the apparent supersaturation of serum results
from a local cellular gradient, is this gradient
under the influence of the parathyroid gland?
Does parathyroid activity influence citrate me-
tabolism in bone?

The cannulation technic previously described
was used to study citrate production in bone in
dogs under varying levels of parathyroid stimu-
lation. Five dogs were parathyroidectomized,
and 14 were given subcutaneous injections of
parathyroid extract. They were compared with
the 9 normal animals. Serum calcium levels in-
dicated the parathyroid hormone level. Average
values were 5.6-, 10-, and 16-mg. per cent Ca for
the operated, normal, and injected dog, respec-
tively. Net citrate gradients were 0.2-, 0.5-, and
0.9-mg. per cent respectively. Thus, a direct
relation between parathyroid activity and citrate
production in bone was observed.

This conclusion might be questioned. It is
possible that the extra citrate was derived from
marrow, not from bone. This problem cannot be
settled with assurance. However, the data in
figure 5 show that the blood sample having the
greater contribution from marrow exhibits the
smaller citrate gradient. In addition, other tis-
sues and organs were studied to learn whether
they contributed measurably to the metabolism

MAY 1958

195

TIME IN HOURS

Fig. 5. Curves showing citrate production by hone and
its response to parathyroid extract injection ( arrow P,
1,000 units). Upper curves show clearance of carrier-free
radiostrontium injected at arrow Sr°. Note that the citrate
level is inversely related to the clearance of radiostron-
tium, indicating hone as source of the citrate. Mixed
venous blood from the general circulation drawn at in-
tervals throughout the experiment exhibit citrate levels
slightly below those of arterial blood. Taken from f.
Am. Chem. Soe. 78:3863, 1956.

of circulating citrate. These studies, though lim-
ited in scope, suggest that the kidney is the pri-
mary site of oxidation of circulating citrate,
while bone is an important source of newly syn-
thesized citrate. Liver may also contribute to
the synthesis of circulating citrate, but other tis-
sues seemed neither to add nor detract from the
circulating supply.

At the present time, the available data are not

1. Barnicot, N. A.: Local action of vitamin A on bone. J.

Anat. 84:374, 1950.

2. Chang, H.: Localized resorption of bone adjacent to para-

thyroid grafts. Anat. Rec. 106:266, 1950.

3. Stewart, G. S., and Bowen, H. F.: Urinary phosphate ex-
cretion factor of parathyroid gland extracts: hormone or arte-
fact? Endocrinology 51:80, 1952.

4. Talmage, R. V., Kraintz, F. W., Frost, R. C., and
Kraintz , L.: Evidence for dual action of parathyroid extract
in maintaining serum calcium and phosphate levels. Endo-
crinology 52:318, 1953.

5. Monahan, E. P., and Freeman, S.: Maintenance of normal
serum calcium by parathyroid gland in nephrectomized dogs.
Am. J. Physiol. 142:104, 1944.

6. Dallemagne, M., and Cartier, P., quoted by Armstrong,
W. D.: in Metabolic Interrelations. New York: Josiah Macv,
Jr., Foundation, 1950, p. 30.

7. Neuman, W. F., and Neuman, M. W.: Chemical Dynamics
of Bone Mineral. Chicago: University of Chicago Press, 1958.

8. Toribara, T. Y., Terepka, A. R., and Dewey, P. A.: Ultra-
filterable calcium of human serum. J. Clin. Investigation 36:
738, 1957.

9. McLean, F. C., and Hastings, A. B.: Biological method for
estimation of calcium ion concentration. J. Biol. Chem. 107:

adequate or convincing. The data suggest, but
do not prove, that localized citrate production
may be somewhat tissue-specific— a special char-
acteristic of the metabolism of bone cells.

Also some evidence suggests that the local
response in bone to parathyroid is not solely an
accumulation of citrate. Analyses for lactate, for
example, revealed a pronounced effect of para-
thyroid extracts on the metabolism of lactate by
bone. In normal animals, the bone seems to be
utilizing lactate. In dogs rendered hvpercal-
cemic by injections of parathyroid extracts, the
bones seem to produce lactate. These are, of
course, onlv preliminary findings, but they sug-
gest that the bone response to the hormone may
turn out to be one of generalized acid produc-
tion. If this proves true, there must also exist a
gradient in pH between bone and blood.

In any event, one thing seems established:
parathyroid hormone exerts potent metabolic ac-
tions. Furthermore, we can, at present, visualize
a mechanism by which this metabolic action
can result in an altered equilibrium between the
body fluids and the bone mineral. The mechan-
ism we have postulated may prove to be incor-
rect in part or in its entirety, but we can rest
assured that this is not the end of the story. On
the contrary, we may have every expectation of
important new advances in our understanding
of bone metabolism. Ultimately, this will lead
to improvements in our concepts and manage-
ment of metabolic bone disease.

This paper is based on work performed under contract
with the United States Atomic Energy Commission at
the University of Rochester Atomic Energy Project,
Rochester, New York.

The author is deeply indebted to Hilliard Firschein,
George Martin, and Betty Jane Mulryan for permission to
describe their observations, largely unpublished, on cit-
rate production by bone under varying levels of para-
thyroid activity.

337, 1934.

Yendt, E. R., Connor, T. B., and Howard, J. E.: In vitro
calcification of rachitic rat cartilage in normal and pathologi-
cal human sera with some observations on pathogenesis of
renal rickets. Bull. Johns Hopkins Hosp. 96:1, 1955.
Strates, B. S„ Neuman, W. F., and Levinskas, G. J.: Solu-
bility of bone mineral II. J. Phvs. Chem. 61:279, 1957.
Shear, M. J., and Kramer, B.: Composition of bone. III.

Physicochemical mechanism. J. Biol. Chem. 79:125, 1928.
Hodge, H. C.: Metabolic Interrelations. New York: Josiah

Macy, Jr., Foundation, 1950, p. 73.

Nordin, B. E. C.: Solubility of powdered bone. J. Biol.

Chem. 227:551, 1957.

Firschein, H., Martin, G., Strates, B., Mulryan, B. J.,
and Neuman, W. F.: Concerning the mechanism of action of
parathyroid hormone I. J. Am. Chem. Soc., in press.
Armstrong, W. D., and Singer, L.: in Bone Structure and
Metabolism, edited by G. Wohlstenholme and C. O'Con-
nor. Boston: Little, Brown & Co., 1956, p. 103.

Neuman, W. F., Toribara, T. Y., and Mulryan, B. J.: The
surface chemistry of bone IX. J. Am. Chem. Soc. 78:4263,
1956.

Ericsson, Y. : Metabolic Interrelations. New York: Jasiah

Macy, Jr., Foundation, 1952, p. 226.

REFERENCES
10.

11.
12.

13.

14.

15.

16.

17.

18.

196

THE JOURNAL-LANCET

Clinical Manifestations of the Autonomic
Nervous System Sequential to Osteoarthritis
of the Cervical Spine

EUGENE NEUWIRTH, M.D., and
LOUIS GAYRAL, M.D.

Great Neck, New York, and Toulouse, France

IN THE COURSE OF OSTEOARTHRITIS of the Cervical
spine (cervical spondylosis), a common con-
dition in persons past the age of 50, osteophytes
develop from the uncovertebral joints or the
apophyseal joints or from both at the same time.
Rony spurs from these joints may jut into the
spinal canal, the intervertebral, and the trans-
verse foramina, where they may cause compres-
sion and irritation of component parts of both the
central and the autonomic nervous systems, thus
giving rise to a wide variety of complex neuro-
logic and neurovascular syndromes. The un-
covertebral osteophytes possess the greater path-
ogenic significance.

In osteoarthritis of the cervical spine, the fol-
lowing autonomic nervous structures may suffer
damage:

1. The vertebral nerve.

2. The autonomic plexus surrounding the ver-
tebral artery.

3. The autonomic nerve fibers which pass
through the fifth to eighth cervical and the
first thoracic ventral nerve roots.

4. The deep chain of autonomic ganglia in the
transverse foramen between the fourth and
the seventh cervical vertebrae.

5. On occasion, the cervical segments of the
sympathetic trunks placed on both sides of
the vertebral column.

The principal symptoms arising from implica-
tion of the autonomic spinoneural structures in
the neck are as follows:

eugene neuwirth is a specialist in physical medi-
cine and rheumatic diseases with offices in Great
Neck, New York, louis gayral is instructor in neu-
rology and psychiatry, medical faculty, University
of Toulouse, Toulouse, France.

Paper presented at the ninth International Con-
gress on Rheumatic Diseases in Toronto, Canada,
June 23 to 28, 1957.

1. Headache.

2. Facial pain (sympathalgia and atypical
facial neuralgia).

3. Oto-neuro- ophthalmologic manifestations
as they occur in the posterior cervical
sympathetic syndrome of Rarre and Lieou.

4. Pharyngeal, lingual, and laryngeal pares-
thesias.

5. Ocular lesions, including optic neuritis.

6. Vertigo.

7. Neurotrophic rheumatism of the upper ex-
tremity or the shoulder-hand syndrome.

8. The neurotrophic variety of periarthritis
of the shoulder.

9. Acroparesthesia.

10. Epicondylitis, radial styloiditis, and Du-
puytren’s contracture.

11. Pseudoangina.

12. Functional and organic heart disease.

13. Pseudopsychiatric disturbances.

The clinical patterns due to involvement of
autonomic nervous system structures by cervical
osteophytes may be modified by spinal root or
spinal cord manifestations when these nervous
structures are affected by the skeletal changes of
osteoarthritis. The presence of symptoms caused
exclusively by osteoarthritis itself further multi-
plies the clinical patterns.

The prime question is whether osteoarthritic
projections in the cervical spine as seen in roent-
gen films can be considered the cause of neuro-
logic disturbances. Though crowded with large
osteophytes, neurologic symptoms can be absent,
and the cervical spine itself may be free from
pain. On the other hand, major complaints are
encountered in the face of little structural
change. Furthermore, neurologic symptoms fre-
quently yield to conservative treatment, while
the osteophytes themselves remain unchanged.

MAY 1958

197

To explain the incongruities, it is pointed out
that an inflammatory factor may augment the
mechanical factor of direct compression of ner-
vous structures to bring about neurologic mani-
festations. Fibrosis of connective tissue elements
in the neck, that is, fibrosis of nerve root cuffs,
is another factor which can produce symptoms.
It also should be remembered that an under-
exposed x-ray film is necessary to demonstrate
osteophytes which are only slightly ossified and
that the true size of osteophytes fails to show on
the x-ray film because they are covered with
cartilage.

In conclusion, the writers wish to draw special
attention to three groups of manifestations which
may develop in the wake of cervical spondylosis.

1. Ocular lesions. Contusion and irritation of
the autonomic fibers in the ventral roots by cerv-
ical osteophvtes may cause vasomotor disturb-
ances (vasodilatation) in the internal carotid
vascular tree. This induces development of optic
neuritis, which may result in blindness. Cervical
traction therapy or surgical liberation of the
ventral roots may bring about improvement or
recovery.

2. Cardiac manifestations. Many physicians
claim that there is a causal relationship between
cervicovertebral pathology and certain affections
of the cardiovascular system. It is maintained
that lesions of the cervical spine may produce
cardiac arrhythmias (paroxysmal tachycardia
and extrasystole), coronaritis, and myocardial
heart disease.

3. Psychiatric disturbances. The functional
disturbances underlying the posterior cervical
sympathetic svndrome of Barre-Lieou can be
sufficiently severe to produce pseudopsychiatric
conditions. The vestibular and the paresthetic
forms of the Barre-Lieou syndrome exhibit psy-
chiatric features most frequently. Cenesthopathic
and asthenic forms are most apt to obscure the
characteristic clinical features of the Barre-Lieou
syndrome.

The pseudopsychiatric conditions respond only
to etirtlogic treatment and not to psychiatric
management. Hence, physicians should be famil-
iar with the psychiatric disturbances of cervical
origin and not employ fruitless or dangerous
measures, such as electroconvulsive therapy, but
rather apply proper therapy to the cervical spine.

Fracture of the femur or dislocation of the hip can be rapidly and accu-
rately diagnosed by a sound conduction test. The method is particularly useful
at the scene of an accident, in the emergency room, for multiple fractures, or
with mass injuries.

With the patient in supine position, legs uncovered, a stethoscope is placed
firmly on the symphysis pubis and each patella is struck lightly with a finger.
A clear, distinct sound is transmitted by the unbroken bony column of the
normal side and a softer, less distinct sound by the injured side.

Weekly use of the conduction test indicates progress of healing. When the
sound transmitted by the two sides is equal, roentgenograms almost always
show union of the fracture by callus formation.

Diminished sound transmission is found with all fresh fractures of the
femur above the supracondylar region, not only those with displaced fragments.
Sound changes can also be detected with impacted abducted fractures of the
femoral neck, with bone cysts and tumors, and possiblv effusion of the hip joint.
The sound conduction principle should be adaptable to fractures in other bones.

Effusion in the knee joint, an absent patella, and bilateral bone injury or
disease interfere with performance of the test.

Leonard F. Peltier, M.D., University of Kansas, Kansas City. CP 17:109, 1958.

198

THE JOURNAL-LANCET

Roland G. Mayer, 1891-1958

Roland G. Mayer was born at Summerfield, Illi-
nois, on October 14, 1891. His parents, George
and Louise, moved to Minneapolis where he at-
tended grade school and also North High School
until thev went to New Ulm where he graduated
from high school. From 1910 to 1912, he was a
student at the University of Minnesota, then trans-
ferred to the University of Ghicago where he re-
ceived the degree of Bachelor of Science in 1914.
Two years later, he was granted the degree of Doc-
tor of Medicine at Rush Medical College, Ghicago.
He established a general practice at Cresbard, South
Dakota. In 1923, he took postgraduate work in
urology at the New York Post Graduate School and
Hospital. He then opened an office in Aberdeen,
where he practiced urologv until a few weeks before
his death. In fact, he operated throughout the morn-
ing of the day he entered the hospital as a patient.
In this specialty, he developed a large practice and
was highly respected by patients and their families.
His work and contributions were of such fine quality
that he received high recognition among urologists
everywhere. He was a member of the North Central
Section of the American Urological Association and
the Twin Gitv Association.

He held membership in numerous other medical
organizations, including the Aberdeen District Med-
ical Society, the South Dakota State Medical As-
sociation, the American Medical Association, the
American Association of Railway Surgeons, the
Sioux Valley Medical Association, and the Missis-
sippi Valley Medical Society, of which he had been
vice president.

He contributed greatly to the welfare of organ-
ized medicine, having served on practically all of
the committees of the local and state medical asso-
ciations. No one in his state was more highly re-

spected and trusted by professional colleagues.
Indeed, he was secretary-treasurer of the state med-
ical association from 1943 to 1951 and president
from 1953 to 1954. When the state association de-
cided to publish a journal. Dr. Mayer was chosen
as editor-in-chief. In his characteristic manner, he
not only did splendid editing, but contributed sig-
nificant articles and fine editorials. He took so much
interest in medical journalism that he was active
in the American Medical Writers Association of
which he was a member of the Advisory Committee.
He was also a member of the Board of Directors
of State Medical Journals Advertising Bureau.

A long-time friend, Dr. M. R. Gelber, Aberdeen,
wrote, “With the death of Doctor Mayer we passed
another milestone in the service to humanity. He
did a tremendous amount of work not only for our
district but also for the State Medical Association.
He did everything graciously and willingly and was
always ready to listen to all the sides of any prob-
lem. His passing leaves a void in our ranks which
will be hard to fill for many years. He died as he
lived — bravely.”

Some of the diseases he treated are contagious
and, therefore, he took a special interest not only
in controlling them in his community but in the
state and the nation. He became the Aberdeen City
Health Officer and superintendent of his County
Board of Health. He was physician for the Aber-
deen Public Schools and a member of the American
School Health Association.

His routine practice included many elderly per-
sons, so he took special interest in geriatrics and
became a fellow in the American Geriatric Society.

Dr. Maver continuously emphasized that child-
hood is the best time to teach good health measures.
He served as a member of the South Dakota Sub-

MAY 1958

199

committee on Tuberculosis of the American School
Health Association since December 1944 and as
chairman since February 1954. He worked with the
Brown County and the State Tuberculosis Associa-
tions and participated in the actual testing of school
personnel and children in his county. This was done
so well that most schools qualified for certification.

Following the program of repeating the work
every two years, he arranged for the second round
of testing to begin in January 1957 and to be com-
pleted during the school year. In the summer of
1957, he wrote, “We have found that preparation
for the clinics can be accomplished much more
easily the second time around, and the details, rec-
ords, and conducting the tests all work out more
smoothly.” The demonstration leading to certifica-
tion of schools interested others to the extent that
he was asked to arrange for testing the freshman
class at Northern State Teachers College in Aber-
deen and also the prisoners in the city jail. He felt
that certification of schools was an exceedingly im-
portant project and worked toward the goal of hav-
ing it extended to every school in South Dakota.

He manifested much interest in athletics, includ-
ing baseball, basketball, football, and golf. These
interests took him to the major athletic centers on
both coasts and many other places, including Ha-
waii. He was a fellow of the American College of
Sports Medicine.

Dr. Mayer was thoroughly loyal to organizations
to which he belonged and to individuals with whom
he worked. At the 1957 meeting of the North Cen-
tral Medical Conference, he was elected president
for 1958. When he became ill and was told of his
diagnosis, one of his first requests was that the
conference be informed. Then he himself tried to
locate a successor in his private office in order to
avoid any burden that might come to his co-workers
or lack of care for his patients.

On October 18, 1917, he married Miss Mildred
Austin who died on November 8, 1918. Their son,

Robert, resides in New Orleans. On December 20,
1919, Dr. Mayer married Olive Gabler who, through
the years, has contributed so much to his success
and to the welfare of their community. Their son,
Roland, is engaged in the private practice of medi-
cine in Medford, Oregon, and their daughter, Muriel,
lives in Aberdeen where her husband. Dr. B. F.
Wallace, is a prominent dentist.

Only a few days before his death, Dr. Mayer
called his daughter to his bedside and dictated with
a single word between breaths, “My Last Editorial.”
It is almost the last word of a physician who had
led a full life and had contributed significantly to
the good of humanity. His editorial appears in full
in the January issue of the South Dakota Journal of
Medicine and Pharmacy, which he had edited since
its inception.

Dr. Mayer’s case is a striking example of the ter-
rible chagrin the physician suffers when one of his
best medical friends appeals for help but a hopeless
condition is found. He died from carcinoma primary
in the right lung January 8, 1958. Physicians will
cease to suffer such experiences only when research
is adequately supported to reveal the cause, a bio-
logical test, and adequate treatment for bronchial
and pulmonary malignancies.

As it is to many physicians, Dr. Mayer’s death is
a severe loss to me. We have been close friends and
have worked together on numerous occasions over
the past quarter-century. Whether his work per-
tained to participation in programs, such as the fif-
tieth and seventy-fifth anniversaries of Dakota medi-
cine, the South Dakota Association, and Aberdeen
organizations or to problems pertaining to the health
of school children and private patients and numer-
ous other activities, he alwavs demonstrated unusual
ability, unquestioned loyaltv, and forthrightness at
every turn. To visit or work with him was always
most pleasant and profitable because of his geniality
and ability to teach all with whom he conversed
and worked.

200

THE JOURNAL-LANCET

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23A

Medical Radiation Biology, by
Friedrich Ellinger, M.D., 1957.
Sringfield, Illinois: Charles C

Thomas, 945 pages. $20.00.

The scope of this book is “to cover
our knowledge of the biologic effects
of radiations in their relationship to
diagnostic, therapeutic, preventive,
and military medicine.” This is in-
deed an ambitious undertaking, for
which the author is to be congrat-
ulated. Articles from scientific jour-
nals published in English, French,
and German are comprehensively
reviewed. In all, 4,600 references
are included, making this volume an
excellent summary of progress in
medical radiation biology. The ab-
sence of an index, which limits the
usefulness of this book as a source
of reference material, is at least par-
tially compensated for by the inclu-
sion of a detailed table of contents.

With the ever increasing impor-
tance of ionizing radiations in our
lives, Dr. Ellinger’s book is very
timely. It is divided into 4 parts:

( 1 ) fundamental radiation biology,

(2) biology of ionizing radiations,

(3) biology of ultraviolet radiation,
and (4) photobiology.

Considerable effort goes into a
discussion of macroscopic and mi-
croscopic effects of radiations on
each organ system in the body. Pho-
tographs are used to good advan-
tage to illustrate many of these ef-
fects. It must be stated, however,
that it is not possible to include
sufficient detail on all subjects in
one volume to satisfy the specialist
in a particular area. For example,
the sections devoted to the use of
radioisotopes will not satisfy the
specialist in nuclear medicine. Thus,
this book appears to be most useful
as a means for integrating together
the many facets of radiobiology on
an introductory level.

This book is recommended read-
ing for clinicians and researchers
concerned with the effects of ioniz-
ing radiations on biological systems.

Merle K. Loken, Ph.D.

•

The Spine Anatomico -Radio graphic
Studies, Development and the
Cervical Region, by Lee A. Had-
ley, M.D., 1957. Springfield, Illi-
nois: Charles C Thomas, 156

pages. $6.50.

This short treatise dealing with the
spine is well illustrated with roent-
genograms, diagrams, and photo-
graphs. The author, a roentgenol-
ogist, concentrates on lesions of the
cervical spine, with special orienta-
tion to x-ray diagnosis. He describes

in detail a method of visualization
of the cervical intervertebral for-
amina by the oblique radiograph. In
this area, x-ray diagnosis is confusing
because of superimposed irregular
surfaces. Accurate identification of
the structures is essential in any
assessment of the cervical interverte-
bral foramina. Dr. Hadley’s technic
produces clear visualization of the
structures by the oblique radiograph.

Differential diagnosis of congenital,
traumatic, inflammatory, and de-
generative lesions of the cervical
spine is the main problem studied.
Normal development of the vertebra
is traced from its embryologic be-
ginnings in the prenatal period
through its postnatal growth and
ossification. Abnormal development
processes are considered. Clear radio-
graphs and diagrams aid the dis-
cussion of disordered segmentation,
nonsegmentation, lack of fusion, and
spinal dysraphism.

The practical significance of this
background material becomes clear
in the second half of the book in
the discussion of specific disease en-
tities. The congenital anomalies are
discussed with their clinical mani-
festations and in their differentiation
from traumatic conditions, such as
whiplash injury and cervical sub-
luxation. For example, the ossiculum
terminali of the odontoid may be
confused with odontoid fracture.
Such differential diagnoses of trau-
matic and congenital abnormalities
of the cervical spine are common
medicolegal problems.

Foramen magnum encroachment
is of some clinical significance, as
it may be confused with a variety
of conditions, including multiple
sclerosis and syringomyelia. It may
be due to such lesions as atlanto-
oecipital fusion or to accessory emi-
nences about the foramen magnum.
The symptoms may develop onlv
after the second or third decade and
then may be progressive or fatal.

Basilar impression is an invagina-
tion of the posterior cerebral fossa
and may be associated with flatten-
ing of the basilar angle. Platybasia
is basilar angle flattening, desig-

nating only that portion anterior to
the foramen magnum. These con-
ditions are clearly illustrated with a
number of radiographs.

Intervertebral foramen encroach-
ment may be due to osteophvte pro-
duction from degeneration of disk,
covertebral joint, or posterior
apophyseal joint. Such encroachment
may produce bizarre symptoms in
addition to the usual local and re-
ferred symptoms. Such bizarre symp-
toms are thought to be caused by
pressure on the vertebral sympa-
thetic plexus. This section is followed
by the author’s standard technic for
the oblique cervical radiograph. The
appearances of the normal for this
technic are described.

John Moe, M.D.

•

Dermatologic Formulary, edited by
Frances Pascher, M.D., ed. 2,
1957. New York: Paul B. Hoe-
ber, Inc., 172 pages. $4.00.

This compact volume on dermato-
logic therapy is the second edition
of a formulary emanating from the
New York Skin and Cancer Unit.
The first section of the book deals
with topical measures. Following a
brief description of each proprietary
product or dermatologic prescrip-
tion, explanatory notes on actions,
uses, indications, contraindications,
and directions for use are given.
Systemic therapy is presented in the
second section. Included are many
useful oral and parenteral drugs.
Again, after a brief description of
the preparation, its action, uses, in-
dications, contraindications, and di-
rections for use are given. The next
portion of the book deals with local
anesthetics, biologicals, cauterizing
agents, dressings, and so forth. The
final section contains some useful
therapeutic aids and samples of
printed instructions for patients.
This book is well indexed for ready
reference. It contains a wealth of
authoritative information on der-
matologic therapy and should be a
valuable aid to all practitioners.

Elmer M. Hill, M.D.

•

Urine and the Urinary Sediment,
by Richard W. Lippman, M.D.,
ed. 2, 1957. Springfield, Illinois:
Charles C Thomas, 140 pages.
$8.50.

This monograph, first published in
1952, is designed to “serve as a
practical guide in the clinician’s ex-
amination of urine and the urinary
sediment and as a record of meth-
ods and interpretations that have
(Continued on page 26A)

24A

5801

@ SPECIFIC ANTITUSSIVE...

“COTHERA'' moderates intensity and frequency of coughing
through a selective action apparently on the medullary cough center
. . . subdues but does not abolish the cough reflex. The natural reflex
for removal of secretions is retained.

ACTS WITHIN MINUTES — LASTS FOR HOURS...

“COTHERA” provides a local anesthetic and soothing demulcent
action to induce almost immediate relief of ‘sandpaper’ throat and
‘annoying tickle’. . . followed by sustained moderation of the cough
reflex, lasting for four to six hours and frequently throughout an
entire night with one dose.

NON-NARCOTIC...

“COTHERA” is nonaddictive; does not cause respiratory depres-
sion, gastric irritation, or constipation. It is well tolerated by chil-
dren and elderly patients, even after continued use. (Antitussive
action is equal to 14 gr. codeine per teaspoon dose.)

GUARDS AGAINST BRONCHOSPASM . . .

“COTHERA” exerts a mild musculotropic spasmolytic action tend-
ing to protect against possible harmful effects and cough-aggrava-
tion of bronchospasm.

CHERRY-FLAVORED...

“COTHERA” is completely acceptable to all age groups.

Indications: “COTHERA” Syrup is specifically indicated for irritating,
useless, or chronic coughs such as those associated with the common cold,
children’s diseases, excessive smoking. It may be used safely for short-
term or prolonged treatment.

Dosage: Adults and children over 8 years — 1 to 2 teaspoonfuls (25-50
mg.) three or four times daily. Children, 2 to 8 years — 14 to 1 teaspoonful
three or four times daily.

Supplied: 25 mg. per 5 cc. (teaspoonful), bottles of 16 fluidounces and
1 gallon.

Ayerst Laboratories

New York 16, N. Y. ‘Montreal, Canada

25A

BOOK REVIEWS

(Continued from page 24 A)
evolved during a long period of care-
ful observation.” The text of the
second edition has been extended to
include short discussions of addi-
tional topics, such as chyluria, virus
infections, purpura, potassium de-
pletion nephropathy, sickle cell
anemia, polycythemia, and physical
trauma. Thirty-six additional color
plates have been added, making a
total of 92, which maintains the
fine quality of the first edition, and
the bibliography has been extended
from 93 to 232 references.

The basic outline of the original
edition is maintained. In the first
section, Dr. Lippman presents a
concise discussion of the clinical
and pathophysiologic significance of
proteinuria and each of the formed
elements of the urinary sediment.

The second section is concerned
with specific clinical diseases and
the urinary findings in each, which
are correlated with the underlying
pathologic process within the kid-
ney or urinary collecting system.
Special emphasis is placed on the
fact that the findings of urinary ex-
amination reflect only the pathologic
process and must be considered in
the light of clinical findings in order
to attain proper significance.

The final section of the mono-
graph is devoted to general consid-

erations regarding urine volume, its
appearance, odor, and so forth and
technics of urine collection and gen-
eral examination, equipment, and
material necessary for basic office
procedures and an outline of the
special technics involved in testing
for about 30 abnormal urinary con-
stituents.

This monograph serves as a guide
to the technic and interpretation of
more complete urine analysis and
also as an excellent atlas of the uri-
nary sediment.

Donald Bravick, M.D.

©

Methods in Surgical Pathology, by
Henry A. Teloh, M.D., 1957.
Springfield, Illinois: Charles C

Thomas, 127 pages. $4.75.

This small volume is written for the
beginning student in surgical pa-
thology, instructing him i$ the prop-
er handling, gross description, block-
ing, and microscopic examination of
surgical tissues. The writing is
straightforward and concise but still
detailed, covering in the 36 chap-
ters the fine points of examination
in all the major body systems. Sepa-
rate chapters discuss frozen section,
bacterial and fungus cultures, and
prognosis in surgical pathology. This
book fills a definite hiatus in the
material written for resident train-
ing and, as such, should find wide

acceptance in all hospitals or insti-
tutions giving instruction in patho-
logic anatomy.

John I. Coe, M.D.

o

Doctors and What They Do, by

Harold Coy, 1957. New York:

Franklin Watts, Inc., 180 pages.
$2.95.

This is an interesting and very com-
plimentary book pertaining to the
profession of medicine. It is a
round-by-round description of the
life of a doctor. First, the reader
meets him on his daily calls doing
his best to cure, relieve, or comfort
his patients. Then follows the re-
action of hopeful anticipation and
solace on the part of the patient
and family to the doctors presence.

Various chapters discuss the fam-
ily doctor, the specialist, the hos-
pital, the public health organization,
and the various advances made in
the medical and surgical fields
which have saved lives.

The book is an excellent espousal
of the nobility of medicine.

The description of the doctors
life, the educational requirements,
the labor involved, and the satisfac-
tions gained make it a good refer-
ence book for high school and col-
lege libraries for students who con-
template the career of medicine.

Arnold S. Anderson, M.D.

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26A

Prefatory Note from the Director-General of WHO

Dear Professor Anderson:

It is most gratifying to learn that The Journal Lancet is devoting its June
issue to public health matters, as a most appropriate way of marking the occasion
of the Eleventh World Health Assembly which is meeting in Minneapolis during most
of that month. I believe I need not tell you what a great pleasure it will be for
all those participating in the Assembly either as members of delegations or of the
Secretariat to have this opportunity of visiting your State which has achieved
such outstanding progress in the field of public health.

Compared with therapeutic medicine, the roots of which reach deep into the
soil of history, public health and preventive medicine are relative newcomers.
However, in the last hundred years and particularly during the present century,
they have made considerable advances. It is being gradually realized that
therapeutic and preventive medicine are really inseparable and an ever-increasing
effort is in progress to make the doctors of tomorrow more preventive-minded.

There is good evidence that today, governments and peoples are accepting that
health, like peace, is indivisible, and that it is in each country's interest
that the peoples of other countries should live in healthy conditions. More and
more widely the definition of health given in the Constitution of the World Health
Organization — "a state of complete physical, mental and social well-being" — is
being adopted as an attainable if distant goal.

The combined techniques of clinical medicine and public health can together
work veritable miracles in raising levels of health, and levels of prosperity too,
throughout the world. This is the vision and the belief on which the work of the
World Health Organization is founded. During its first decade of existence,
it has benefited greatly from the support of your Government in its councils, and
the co-operation of some of your best health experts in its programmes. One
important advantage that we shall derive from the generous invitation of your
Government to hold this year's Assembly in Minneapolis will be the occasion thus
offered to strengthen these links with the medical profession in your great country.

Yours sincerely,

TH

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STATE OF MINNESOTA

EXECUTIVE OFFICE
SAINT PAUL 1

To All Delegates and Representatives
to the

Eleventh World Health Assembly:

On behalf of the citizens of the State of Minnesota it is my privilege
to extend our most sincere welcome to each of you. Your presence is
indeed an honor.

The achievements of the World Health Organization are an inspiration
to all of us. History will reveal the ultimate victories to overcome
the present burden of human suffering secured through the courageous,
sustained efforts of the member nations of the World Health Organizatlc

We are united with you in the firm belief that "unequal development in
different countries in the promotion of health and control of disease,
especially communicable disease, is a common danger." Without question
"health of all peoples is fundamental to the achievement of peace
and security."

We take pride in the fact that citizens of this State have had the
opportunity to take part in your deliberations at previous World Health
Assemblies as delegates from the United States of America. The State
is honored that some of its citizens presently are privileged to serve
on your expert advisory panels, and a number of them are members of
WHO technical assistance teams serving in many parts of the world.

That our University of Minnesota has been selected as a training centei
for medical and health personnel from all parts of the world is a dis-
tinction in which we take considerable satisfaction.

Most of us are unable to make a direct contribution to this global
battle through the application of our technical skills, but I can assuj
you that all of the citizens of this State are strong in their support
of your great contribution to international health and world understanc

Orville L. Freeman
GOVERNOR

Welcome

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fir Dr. Anderson:

( behalf of the University of Minnesota I am delighted to extend
:ordial welcome to the representatives of the 88 nations in the
•Id Health Organization. We are happy to have you on our campus
l in our state.

itever devices man can conceive to promote world peace, ultimately
i goal is to bring the peoples of the world closer together and
■o greater understanding of each other. Surely the World Health
:anization through its International Sanitary Regulations, the
ndardization of drugs in international units, the promotion of
•ernation health research, and the world-wide dissemination of
.1th information in making a signal contribution toward this ob-
tive.

is our earnest wish while you are in our state to do everything
sible to make your visit here a productive and enjoyable one.
are proud of the health record of the people of our state and
their support of medical education as represented in the Univer-
y's College of Medical Sciences. We are proud, too, of our
ationship with the world-renowned Mayo Clinic in Rochester and
i our association with them in graduate medical education through
Mayo Foundation of the University's Graduate School.

is a privilege to have the World Health Organization in our midst,
humanitarian objectives and its vital effectiveness in the work
the United Nations we salute.

tfh friendly greetings.

f

Sincerely,

(_ ~ll*o -wJ2£

J. L. Morrill
President

Robert N
Secreta;

Barr.

M.O.

ry and Executl

OPfic

M AYO CLINIC

ROCHESTER, MINNESOTA

SURGICAL SECTION
C. W. MAYO, M. D.

To all Delegates and Representatives
to the

Eleventh World Health Assembly:

It is my privilege and pleasure, as chairman of the
Minnesota WHO and Centennial Health Committee, to extend
heartfelt greetings to each of you.

Having served twice as a member of the United States
Delegation to the World Health Assembly, I am aware of the multi-
tude of problems pertaining to the health and welfare of man as a
whole, with which you are and will be confronted. Your dedicatio
to practical deliberations in the interest of better health and t
carrying out of needful technical assistance will achieve more th
international improvement of health. It epitomizes man's concern
for man beyond national boundaries and must therefore be a moral
force of inestimable value in the promotion of what is closest to
the heart of man — a continuing meaningful peace.

As we greet old friends and make new ones, let us
not lose sight of our real objective -- a united effort to improv
health of man, whoever and wherever he may be.

May your deliberations be profitable to the cause and
may your stay in Minnesota be pleasant. We are honored by your
presence .

Charles W. Mayo, M.D.

SERVING THE MEDICAL PROFESSION OF MINNESOTA,
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

FOREWORD . Never before in the 89 years of Journal-
Lancet’s history has it been possible to publish an issue
concerning health of people and their domestic animals on a
global basis. With Minnesota celebrating its hundredth year
of statehood and with the World Health Organization hold-
ing its nth annual Assembly meeting here, a unique op-
portunity loomed to present the readers of this Journal with
health information from everywhere on earth. It is our good
fortune to be located in the shadows of one of the world’s
excellent Schools of Public Health and an efficient State
Board of Health only two years younger than The Journal-
Lancet. The contents of this issue of international scope were
made possible by Dr. Robert N. Barr, executive secretary of
the Minnesota State Department of Health, and Dr. Gaylord
W. Anderson, director of the School of Public Health, Uni-
versity of Minnesota.

We are especially grateful to Dr. Anderson who kindly con-
sented to serve as guest editor for the large volume of work
required to organize, procure manuscripts, and edit this issue.

It is a genuine pleasure to speed on its way this special issue,
the contents of which should be helpful to workers every-
where in their promotion of individual work and projects
insuring better health and longer, happier, and more effi-
cient living for the citizens of the world.

J. ARTHUR MYERS, M.D.

LEST WE
FORGET”

The tumult and the shouting dies;

The Captains and the Kings depart:
Still stands Chine ancient sacrifice,

An humble and a contrite heart.
Lord God of Hosts, be with us yet,

Lest we forget— lest we forget !

Rudy ant Kipling 1897

A

■Tv great celebration was terminating
when Rudyard Kipling penned his inspir-
ing “Recessional" which contains this so-
bering challenge and warning. Although
written for a certain occasion, these lines
may nonetheless be appropriate to many
other observances, including that to which
Minnesota is currently the honored host.

Both the City of Minneapolis and the
State of Minnesota are proud and gratified
that the World Health Organization has
chosen to hold its annual Assembly in our
midst. We are pleased that the year in
which we can serve as host should be that
in which the Organization is celebrating
ten years of remarkable accomplishment.
The Journal-Lancet joins in extending to
our visitors a most cordial welcome and
heartiest congratulations. The story of
progress told in this issue far exceeds the
fondest hopes of those who at the end of
World War II envisioned what might be
done by a strong international health agen-
cy supported by the family of nations and
dedicated to human welfare without re-
gard to race, color, creed, or political phi-
losophy. What has been accomplished rep-
resents international cooperation at its best
and should give courage and new hope to
all who believe that world peace is pos-
sible through mutual understanding and
service. The |ournal-Lancet is proud that
it can tell this storv to its readers.

As we review international accomplish-
ments, it is well in this centennial year
of Minnesota that we should also pause
to examine progress in public health. The
past hundred years have been marked by
outstanding accomplishments in disease
control. Many diseases that were common-
place to our grandparents have all but
vanished. The expectation of life has in-

creased and no longer are our cemeteries
crowded with the bodies of small children
whose deaths were so unnecessary.

As we pause to pay well -deserved respect
to those who have made health progress
possible and to celebrate the accomplish-
ments of the past decade in world health,
let us not forget our obligations. As we here
in Minnesota reflect upon our good fortune
of freedom from diseases of major import
in other countries, let us avoid the temp-
tation to complacence. May we remember
that, while our problems differ, we have
nonetheless a duty to achieve reductions in
other diseases which each year exact a
heavy toll of needless illness and death.

Of even greater importance is our obli-
gation to furnish strong support to interna-
tional agencies, such as the World Health
Organization. Poverty and disease are the
seedbed of unrest. So long as we realize
that over half of the world still lives under
thatch and mud, that in spite of remark-
able progress millions of lives are being
needlessly lost each year, that children in
many areas have never known the feeling
of a full stomach — so long as such condi-
tions exist, we can never with a clear con-
science escape our personal and national
obligation to share to our utmost in help
to our fellowman wherever he may be in
need.

The Journal-Lancet joins gladly in the
welcome to our visitors and extends to them
and their organizations its heartiest con-
gratulations. This is a joyous and proper
celebration of remarkable achievements.
At the same time may we hope that those
of us who remain after our visitors depart
will heed Kipling’s warning against com-
placence, “lest we forget — lest we forget.
Gaylord W. Anderson, M.D., Guest Editor

Regional
l)ii •ectors

of the
ff orld Health
Organization

I. C. Fang, M.D.

World Health Organization Regional
Director for the Western Pacific

Fred L. Soper, M.D.

World Health Organization
Regional Director for the Americas

Chandra Mani, M.D.

World Health Organization
Regional Director
for Southeast Asia

W

Paul J. J. van de Calseyde, M.D.

World Health Organization
Regional Director for Europe

F. J. C. Cambournac, M.D.

World Health Organization
Regional Director for Africa

A. H. Taba, M.D.

World Health Organization
Regional Director
for the Eastern Mediterranean

Health

in Africa

F. J. C. CAMBOURNAC, M.D.

Brazzaville, French Equatorial Africa

The African region presents a variety of cli-
matic conditions, including two deserts and
one temperate zone in the south, areas of high
altitudes with equatorial or tropical climates
similar to temperate climates, and small areas^
with perpetual snow. In addition to this diver-
sity of environment, Africa is also comprised of
a variety of ethnic groups and habits.

The problems found in Africa in the field of
public health are on the whole not very different
from those found in many parts of the world,
and, during the last ten years, very important
developments have taken place in the field of
public health.

Each government in the African Region of
WHO endeavors to solve these problems accord-
ing to the means available and the magnificent
results already achieved, which no doubt are
among the most valid ever undertaken in Africa,
are only matched by the formidable task still
to be accomplished.

f. ;. c. cambournac is World Health Organization
regional director for Africa and is located in the Re-
gional Office at Brazzaville, French Equatorial Africa.

The WHO Regional Office started its work in
Africa in 1952.

The role of WHO consists, within its limited
means, of assisting governments in their endless
task, and, whenever these problems extend be-
yond the national political boundaries, it at-
tempts to coordinate efforts in order to ensure
greater effectiveness.

Historically, the activities of health services
tended to meet the immediate demands; in other
words, to fight the great endemics of smallpox,
sleeping sickness, yellow fever, malaria, yaws,
leprosy, and so forth, but, at the same time, the
basic services were developed according to pos-
sibilities.

Yellow fever has practically ceased to present
a menace in Africa. Banned from the cities,
thanks to mass vaccination, the disease is nowa-
days confined to certain forest or bush areas,
where some animal species constitute an inex-
pungable virus reservoir which can be controlled
at the price of a few elementary precautions.

The fight against smallpox has given rise to
some of the greatest victories of man over the
opposing forces of nature. Smallpox has not

JUNE 1958

207

been eliminated from the African continent, but
it no longer creates havoc among entire popu-
lations.

Sleeping sickness and animal trypanosomiasis
have been brought under control in most in-
habited territories. Almost everywhere, the in-
cidence of the disease has been reduced to a
negligible level. The era of great epidemics is
past, thanks to effective and unrelenting control.
Nevertheless, in spite of all efforts, animal trypa-
nosomiasis still presents many a technical and
complex problem which the governments en-
deavor to solve, particularly through measures
aimed at eradication of the tsetse Hv.

Thanks also to the introduction of such pro-
ducts as residual insecticides, new antimalaria
drugs (particularly chloroquine and pyrimetha-
mine), penicillin, and sulfones, it has been pos-
sible in the course of the last decade to reduce
considerably the prevalence of such scourges as
malaria, venereal diseases, treponematosis and
leprosy.

The discovery of new antituberculosis drugs,
such as streptomycin, PAS, and isoniazide, may
one day allow the launching of a mass attack
against tuberculosis, which is found to affect
more Africans than originally thought.

The most gratifying results have been achieved
in the fight against yaws, the most hideous of
all treponematoses, which affected some 20 mil-
lion Africans of which some 5 million are already
cured.

Lesser known to the public, other diseases,
such as bilharziasis and onchocerciasis, are still
difficult to combat. Nevertheless, vast areas in
which onchocerciasis had driven away the popu-
lation have been reclaimed thanks to the eradi-
cation of the vector fly.

The very conditions under which the great
endemics were fought also determined the struc-
ture of health services in Africa. On the one
hand, there are the fixed urban centers, which
are served by the hospital, the dispensary, and
the treatment center, and, on the other hand, the
mobile units serve the rural areas and perform
large-scale mass vaccinations.

The incidence of diseases, such as malaria,
bilharziasis, and tuberculosis, is still so high in
Africa that repercussions on economic and social
conditions are undeniable.

Health of the population is one of the basic
principles of economic and social development
anywhere in the world. However, since public
health depends greatly upon the economic and
social conditions prevailing in a given country or
territory, the intimate interdependence of health,
social, and economic factors is understood. In

other words, in the absence of a general improve-
ment in living standards, no large scale progress
can ever be attained.

The governments of this region are fully aware
of this inter-relationship, and they have always
endeavored to bring their efforts to bear simul-
taneously on all levels of public life. Progress in
one sense may be irremediably compromised or
defeated in the absence of combined efforts in
other fields.

This state of affairs, which has existed in Africa
for centuries, calls for the following general
considerations, which the governments found
through experience and which WflO now at-
tempts to acknowledge.

1. For many years to come, the fight against
the great endemics will continue to claim the
brunt of the activities of the public health ser-
vices.

2. If the activities of these services are some-
times sufficiently comprehensive to deal with the
situation in urban centers, they are still insuffi-
eient in the rural areas.

In order to establish more comprehensive,
better equipped and more effective services, the
number one problem consists of training more
personnel at all levels from the medical doctor
to the most humble health auxiliary in the bush.

Without prejudice to the indubitable advan-
tages presented by mobile units in the emer-
gency battle against one or the other of the great
endemics, present trends are toward the estab-
lishment, as far as possible, of rural health cen-
ters with many-sided activities, both curative
and preventive, to gradually replace the purely
mobile services.

Finally, within the health services, more and
more emphasis is placed upon providing spe-
cialized personnel and the development of serv-
ices in the field of maternal and child welfare,
nursing , nutrition , environmental sanitation and
hi/giene, and health education of the public.

Anv improvement of these 5 factors is once
again closely related to economic resources and
social factors which determine the ways of life
of the African populations.

To a large extent, the assistance lent to coun-
tries and territories in Africa by WHO consists
of the organization and coordination of surveys
and campaigns, particularly in the fields of com-
municable diseases, control, and nutrition. In
addition, attempts are being made to strengthen
the extensive network of national health services
so they will be capable of absorbing and ad-
ministering the special services set up to solve
specific problems. In accordance with the gen-
eral policy of the organization, a growing import-

208

THE JOURNAL-LANCET

ance is being attached to the development of
basic public health services. Hence, priority has
been given to training and instructing personnel,
as this is the best way to reinforce and develop
existing health services.

This form of assistance, either through actual
control in the field, the creation of pilot areas,
the provision of consultants and specialists, or
training courses and fellowships, accounts for 90
per cent of the combined budgets of WHO, the
United Nations Technical Assistance Board, and
the United Nations International Children’s Fund
(UNICEF) in Africa. By the end of 1957, the
contributions from these sources toward im-
proved health conditions in the African continent
amounted to some $15,000,000.

THE FIGHT AGAINST COMMUNICABLE DISEASES

Malaria. Of the total African population south
of the Sahara, an estimated 116 million people
live in malaria-ridden areas in which they are
continuously exposed to the disease. However,
great progress has been made against malaria,
particularly, in post-war years. For many years,
the western coast of Africa has not deserved its
reputation of the “White Man’s Grave.

Of all tropical diseases, malaria is undoubtedly
the most devasting. It slowly weakens the human
body, thus preparing the way for fatal develop-
ments. Because of the immunity acquired by the
African in early childhood, which protects him
in adulthood, malaria mortality chiefly affects
the infant group. Is this not a heavy price to
pay for this immunity which enables the African
to support a number of mosquito bites day after
day or, rather, night after night without apparent
ill-effects, one of which would suffice to infect,
a nonimmune person?

It is only natural that the fight against malaria
was initially confined to the urban centers. The
discovery of residual insecticides, particular}'
DDT ( dichloro-diphenyl-trichloro-ethane), and
the introduction of mass spraying methods in the
years following the last war completely changed
the approach to malaria control. Previously, con-
trol was largely defensive. However, with the
new insecticides, man began to attack his num-
ber one enemv, the Anopheles mosquito, this
terrible vector of malaria which, in the past,
brought about the ruin of several civilizations.
It was in the Natal province (Union of South
Africa) that the control of malaria by fighting
adult mosquitoes took place when only pyreth-
rum was available as an insecticide.

Bv restricting malaria control to the urban
centers, it was possible to protect many people
within a small area without great expense. The

problem is very different, however, in rural areas,
and the difficulties encountered are almost in-
superable. As the areas to be protected increase
in size and the population to be covered becomes
scarcer, one is faced with problems of time
and transportation, recruitment and training of
specialized personnel, provision of the necessary
spraying equipment and insecticides, the atti-
tude of the population and the opposing natural
conditions, but, above all, the often unexpected
and unforeseeable variations in the bionomics of
the vector mosquito according to environment.
It was soon found that without sound and accu-
rate planning, any control campaign was doomed
to failure.

Nevertheless, the governments concerned cou-
rageously attempted to solve an apparently des-
perate problem. The results obtained in some
parts of the world— South America, Europe, and
Asia— were most encouraging, although condi-
tions were very different. In the Union of South
Africa and in Swaziland, it was proved that mal-
aria can be eradicated in subtropical areas, as
evidenced by results achieved in certain malar-
ious areas of the Transvaal.

In the field of research, a number of centers
were established in several parts of the continent,
such as the East African Institute of Malaria and
Vector-borne Diseases at Amani (Tanganyika),
the Federal Malaria Service of Nigeria in Yaba-
Lagos, the Service General d'Hygiene Mobile et
de Prophvlaxie (SGHMP) laboratories in Bobo-
Dioulasso (French West Africa), the laboratories
in Salisbury (Federation of Rhodesia and Nyasa-
land), the Malaria Centre in Lourenco Marques
(Mozambique), and the laboratories in the Bel-
gian Congo. Several of these centers enjoy active
support from WHO, which, in 1950, convened
the first African Conference on Malaria in Kam-
pala (Uganda) to study the conditions of control
in the African continent.

As a result of this conference, it was decided
to establish a number of pilot zones representa-
tive of geographic and climatologic conditions
in a given area, which, if results were satisfac-
tory, would be the starting points for mass mal-
aria control campaigns. The prinicipal approach
was an attack on the adult mosquito by means of
various insecticides, the comparative values of
which were being studied concurrently, particu-
larly DDT and BHC (benzene hexachloride), to
dieldrin, chlordane, and lindane which were add-
ed later. For five years, that is, until 1955, the
resolutions of the Kampala Conference were en-
forced practically everywhere in the continent.

WHO was able to participate directly in the
efforts of the governments in several countries

JUNE 1958

209

and territories with material assistance from
UNICEF in some instances, and control cam-
paigns were rapidly extended. Bv the end of
1955, the results already obtained were consid-
ered most encouraging. In some countries, such
as the Union of South Africa, Southern Rhodesia,
Swaziland, and Madagascar, malaria seemed to
he nearly eradicated. In any event, the disease
no longer presented a major public health prob-
lem in these territories.

However, in the fall of 1955, when the second
Mai aria Conference in Africa convened in Lagos
under the auspices of WHO, the participants re-
ceived a shattering piece of news. In the Sokoto
pilot area, some anopheline species appeared to
resist insecticides. Fortunately, however, they
seemed to resist only certain products, such as
dieldrin and BHC, and did by no means compro-
mise the encouraging results already obtained,
but the alarm was given.

The problem is very complex in most areas of
Africa, and, in view of the many technical diffi-
culties set forth at the Lagos Conference and the
lack of accurate knowledge of the often myster-
ious conditions which accompany the occurrence
of malaria in Africa and, above all, of the be-
havior of its main vector, A. gambiae, the par-
ticipants acknowledged that complete interrup-
tion of malaria transmission in this region was
still out of reach. But, it was also recognized
that results already obtained in many parts of the
continent justified great hopes.

The already very high costs of malaria control
may run even higher in areas where the applica-
tion of insecticides alone proves inadequate and
where antimalaria drugs must be distributed to
the population in an attempt to pave the way for
malaria eradication through combined action
against both the human and the insect reservoir.

Following the Lagos Conference, the entire
approach to malaria control in Africa was re-
viewed, with particular reference to control con-
ditions in the equatorial belt of the continent
where, after an often spectacular drop, the in-
fection rate tends to remain at a certain level des-
pite efforts to reduce it further.

Among the main measures advocated by the
malaria experts were the establishment of new
pilot zones, where research and practical study
may enable gradual and nation-wide extension of
future mass campaigns.

In addition, WHO set up a number of malaria
advisory teams for on-the-spot study of con-
trol conditions and methods upon request of the
governments. Another special team was also set
up to study the behavior and bionomics of A.
gambiae, man’s principal enemy in Africa. It is

hoped that in not a too distant future the work
under way will result in methods with which it
will be possible to undertake malaria eradication
in the whole African region.

Yaws and other treponematoses. In the fight
against the great endemics of tropical Africa, the
most gratifying results are undoubtedly those
against yaws. The success of yaws control is not
only wrought by the magic of penicillin but also
to a very great extent by the painstaking and un-
relenting efforts of the health sei vices and the
enthusiasm of the public in the f; ce of the spec-
tacular results obtained in so short a time.

In the early postwar years, an estimated 20
million people suffered from yaws in Africa. Bv
the end of the first quarter of 1957, 5 million
people had been treated, requiring the examina-
tion of some 8 million persons living in endemic
arpas of yaws.

The establishment of rural health services is
greatly facilitated because of the interest and
enthusiasm aroused in the population bv the
successful development of the vaws campaigns,
and, in some areas, for instance, in Nigeria, the
population is sufficiently interested to pay for the
establishment of health centers.

Leprosy. The introduction of sulfones brought
hope to the hearts of all those stricken with this
age-old infection. Moreover, it also enabled
mass case-finding and treatment campaigns to be
launched between 1951 and 1953. Todav, the
battle against leprosy in Africa, which has now
reached its culminating point, is the largest ever.

The number of Africans stricken with this
disease is difficult to assess, for here too accu-
rate statistics are lacking in many parts of the
continent. In French West Africa, French Equa-
torial Africa, Gambia, Ghana, Nigeria, and Ugan-
da, where WHO and UNICEF participate in the
battle against leprosy, it is estimated that case-
finding alone will involve examination of some
60 million people. According to present esti-
mates, the total number of people afflicted with
leprosy in Africa ranges from l'A to 2 million,
as compared to a world total of some 10 or 12
million. Of these, around 1 million are already
receiving treatment.

In French Equatorial Africa, the number of
cases treated by the mobile units of SGHMP in-
creased from 2,200 cases in 1951 to 118,000 in
1956 and reached about 140,000 in 1957.

In Uganda, 30,000 leprosy patients were treat-
ed in 1956 as against 4.000 in 1951.

In Nigeria, around 250,000 persons are under
treatment for leprosy and as many in the Belgian
Congo, while about 125,000 patients are already
under treatment in French West Africa.

210

THE JOURNAL-LANCET

One is surprised to note the enthusiasm with
which the leprosy patients submit themselves to
treatment. In French Equatorial Africa, for in-
stance, of 118,000 patients treated in 1956, 98,000
had not omitted one treatment session over the
last two years. Needless to say, an organization
providing such treatment and operating on week-
ly or fortnightly treatment tours, requires consid-
erable means, particularly transportation. The
breakdown of one vehicle may mean interrupting
treatment of 2,000 patients. And if, as in most
cases, there ai-e no roads at all, well, there are
bicycles, camels, horses, and even pirogues.

The leper suffers from two diseases: leprosy
and being a leper. For many centuries, through-
out the world, the unfortunate leper was con-
sidered an object of horror and dread, banned
from society, and condemned to live in abject
misery in the so-called leprosary. Today, much
of the stigma attached to leprosy has been lifted,
and the leprosaria are gradually being replaced
by leprosy villages in which only those who still
present a danger of contagion or who are so
mutilated that they are no longer able to ensure
their own subsistence are kept, often surrounded
by their families, in order to facilitate treatment.

Everywhere in Africa, campaigns are develop-
ing at a growing rate. Wherever WHO does not
play an active part in the physical implementa-
tion of these campaigns, it contributes through
its fellowship program to a widening of the
knowledge of those responsible.

Tuberculosis. It is interesting to note that pre-
cisely at a time when tuberculosis tends to dis-
appear from Europe and North America, its
prevalence is increasing in Africa. This is an-
other example of the inter-relationship between’
the evolution of disease and that of human
society. One may reasonably expect that, just as
the discovery of sulfones enabled mass treatment
of leprosy, the introduction of very potent drugs,
such as streptomycin, PAS, and, especially, iso-
niazide, will soon allow a full-scale attack against
tuberculosis, though preparatory work may be
considerably longer in view of our incomplete
knowledge of the disease and its incidence.

Following the technical discussions at the
WHO Regional Committee for Africa in Luanda,
in September 1956, one of the participants sum-
med up the situation in these words: “The pres-
ent trend of tuberculosis in Africa makes this
disease the most alarming endemv.” The success
achieved throughout the world bv the mass
BCG vaccinations confers a certain authority on
WHO in this field. Their effectiveness is now
acknowledged on condition that the methods of
application are carefully studied in advance.

In view of the concern of the governments in
Africa, WHO decided to set up several survey
teams to collect the necessary epidemiologic data
on the prevalence and manifestations of the dis-
ease in Africa. These teams generally consist
of 1 medical officer, 1 or 2 specialized nurses, 1
x-ray technician, 1 laboratory technician, and 1
statistician. Two such teams were assigned in
1955 and 1956, respectively, to the east and to
the west of the continent.

The work of the teams consists of tuberculin
testing and collecting sputum in a sample group
of the population, as well as administering BCG
vaccinations to the more vulnerable groups and
participating in appropriate health education
activities.

Naturally, governments had already under-
taken to combat the disease in their territories.
Drug treatment campaigns are under wav in
the Union of South Africa. Other WHO and
UNICEF assisted projects are being developed
in Kenya and Nigeria.

Other communicable diseases. Many other
communicable diseases require the attention of
the health services in Africa as elsewhere in the
world. Trypanosomiasis in men and animals is
one of the most important problems in Africa.
There is still much to do before it is controlled,
but the results already obtained by government
services are remarkable.

Two other diseases that are receiving special
attention from WHO in view of their high pre-
valence in some areas are bilharziasis and oncho-
cerciasis.

PRESENT TRENDS

The great majority of Africans live in a rural
environment. The efforts of the governments
were previously brought to bear mainly on the
urban centers where the needs were more press-
ing and where control activities are both easier to
organize and less costly. However, today, the
same governments tend more arid more to de-
velop their health services in rural areas. WHO
plays an important role in this field by consider-
ing with the governments the important and
numerous rural public health problems, by giv-
ing advice on organization and orientation of the
rural services and, finally and above all, by direct
contributions to the control of communicable
diseases. Present trends consist of developing
more comprehensive health services capable of
subsequently absorbing the special services set
up to solve specific problems.

Maternal and child health. The considerable
development which the maternal and child
health services are bound to undergo augurs well

JUNE 1958

211

of the future. These services have existed at all
times. Nevertheless, WHO is endeavoring at pres-
ent to develop them in many different countries
whose governments have requested UNICEF
assistance. WHO keeps informed of progress by
sending consultants to collect data and inform
governments of measures taken elsewhere in the
world. These consultants act somewhat as liai-
son officers, accumulating knowledge and formu-
lating recommendations to ensure more rapid
and less costlv development of these services.

Nursing. Africa lacks medical officers, nursing
personnel, and health auxiliaries. This shortage
possibly constitutes the most critical aspect of
the many public health problems of the conti-
nent. Obviously, no large-scale operations can be
launched as long as there is a shortage of the
necessary personnel. In addition to personnel
called upon to ensure routine nursing services,
emphasis should be placed for many years to
come on training auxiliary personnel for many
large-scale activities, such as mass vaccination
or mass treatment campaigns requiring priority
that may not be assured by specialized personnel
only.

WHO endeavors to provide a teaching staff
of nurses, midwives, and public health techni-
cians to train local personnel who, in turn, will
be able to train other nurses, midwives, and
auxiliaries. WHO also lends assistance to pro-
fessional training institutions, often with material
help from UNICEF. It is also desirable that the
curricula of the schools and, more generally, that
for the training of nursing personnel be stand-
ardized within the continent in order to achieve
higher training standards.

Today, WHO takes part in nurse training pro-
grams in many countries and territories, either
by providing teaching personnel and equipment
or by awarding fellowships which enable the
beneficiaries to acquire new knowledge abroad
in the vast field on which the health of the entire
population so greatly depends.

Nutrition. The problem of nutrition is inti-
mately linked to the problems of agriculture and
soil erosion. It is also closely related to the
supply of meat and fish, and even to certain
taboos. Many different disciplines are involv-
ed: agronomists, educators, veterinarians, medi-
cal officers, and laboratory technicians.

For many years, the governments endeavored
to assess the true state of nutrition in their re-
spective countries. Africa is not so much an
undernourished as a malnourished continent,
where an unbalanced diet may lead to serious
physiologic disorders. The most serious syn-
drome is called “kwashiokor” and may be fatal.

On the other hand, it has been shown that nutri-
tional deficiencies, if not always resulting in such
serious disorders as kwashiokor, favor the occur-
rence of debilitating diseases. The most danger-
ous period occurs immediately after an infant
is weaned, when breast milk is replaced by the
adult diet, which is often poor in proteins.

The governments endeavor to supplement a
deficient diet by enhancing production of new
foodstuffs and by developing stock breeding,
fishing, and fish-farming. If it is fairly easy to
supplement a deficient diet, for instance, through
the distribution of dried skim milk, the problem
becomes utterly involved because of the intro-
duction of new foodstuffs. Great difficulties stem
from certain beliefs and taboos, hence the im-
portance of education.

Health education. The attitude of the popu-
lation toward progress may vary greatlv from
one area to another. It implies many important
anthropologic and social factors which are often
most difficult to distinguish. If once in a while
a spraying team meets the so-called “closed-huts”
attitude or if a given population refuses examina-
tion on religious grounds, for instance, in leprosy
case-finding, the teams may also experience
great difficulties containing a population eager to
receive an injection or treatment of the people
of one village may arouse jealousy of a non-
treated nearby village.

In order to bring the population not enly to
understand and to appreciate but, above all. to
collaborate in the public health activities under-
taken for their benefit, it is necessary to resort to
the many technics of health education. If such
activities are well conducted, the results are most
gratifying as evidenced by the spontaneous
abandonment of psychologic obstacles which
greatly facilitates the work of the health services.
Moreover, health education assures more far-
reaching and enduring results.

Health education activities, therefore, find
their choice application in those fields in which
results are slow and arduous. Health education
does not onlv strive to give people the means
to improve their living but also to teach them the
“art of living."

The WHO sponsored Health Education of the
Public Seminar which took place in Dakar
(French West Africa) in March 1957, gave many
participants an opportunity to study the means
and resources available in Africa to lessen the
conflict between different civilizations and to
enable the people of technically still under-
developed areas to accede to both physical and
mental well-being free from anxiety and disease.

Environmental sanitation. In various terri-

212

THE JOURNAL-LANCET

tories, it was attempted to reduce the incidence
of disease by improving the environment of the
communities, largely through a more sanitary
water supply and the provision of latrine build-
ings. These examples prove that even with
limited financial means, rural living conditions
can be greatly improved.

The WHO sponsored Environmental Sanita-
tion Seminar, which took place in Ibadan (Nig-
eria ) in December 1955, enabled participants to
exchange views and to define a program in this
vast and promising field. Developments are al-
ready important, but much is still to be done and
governments are extremely interested.

COORDINATION OF TECHNICS— OTHER TRENDS

As will be easily understood from this brief out-
line, any efforts undertaken in any one of the
above fields or, preferably in everv one simul-
taneously, require collaboration of specialists
from fields other than the health services: edu-
cation, rural engineering, agriculture, stock farm-
ing, and so forth. Whatever field on which the
governments bring the brunt of their public
health efforts to bear requires full collaboration
between competent and specialist personnel in
a field that may sometimes be very remote from
the purely medical field.

Among the other trends of public health in
Africa are health statistics, mental health, and
certain aspects of atomic energy utilization.

Health statistics are a necessity. With the
growing expansion of administrative and econo-
mic structures in the so-called underdeveloped
countries, the need for basic statistics becomes
imperative, for they alone assure sound planning
for public health problems. The Vital and Health.
Statistics Seminar, which was held in Brazzaville
in November 1956 under the joint auspices of
WHO and CCTA, enabled a summing up of the
situation in Africa and a definition of future
trends.

Mental health is undoubtedly growing in im-
portance in Africa. This is a natural evolution,
similar to that observed today in the highly de-
veloped countries. In 1958, WHO therefore pro-
poses to call upon a number of specialists in this
field to initiate the first seminar on mental health
in Africa.

Peaceful utilization of atomic energy becomes
more and more generalized in medicine, agri-
culture, and industry. In particular use are radio
isotopes, which find their application both in
diagnosis and treatment of diseases and in medi-
cal and biologic research, such as radioactive
marking for the study of vector behavior in flies,
mosquitoes, and so forth. The use of radio-

isotopes automatically brings with it the problem
of protection from radiation. Research workers
wishing to acquaint themselves with the different
aspects of this new science can do so under the
WHO fellowship program.

In Africa, the individual is inevitably condi-
tioned by his environment— climate, environmen-
tal hygiene, and water supply— his nutrition-
shortage of proteins and weaning problems— and
his degree of evolution— illiteracy, beliefs and
superstitions. It is even more inevitable that
these factors also have a major influence on his
physical and mental health.

Therefore, preventive measures in the field of
public health should duly take into account these
three factors, which are so important and which
cannot be dissociated.

From the onset of its activities in Africa, WHO
has endeavored to assist governments requesting
international assistance to solve their problems.
This assistance may consist in the organization
of training courses or the awarding of fellow-
ships. The latter represents one of the most im-
portant aspects of the WHO assistance program
throughout Africa. First, this is true because the
beneficiaries come from every country and terri-
tory of the region; also, because the study pro-
gram includes all the problems of public health
from communicable diseases to anesthesiology
and from public health administration to insect
resistance and the use of radioisotopes. Faith-
fully reflecting the trends of a health policy not
only African but world-wide, at least with re-
gard to the technically less developed countries,
the WHO fellowship program is ehieflv devoted
to the organization and development of health
services according to present trends ( 53 per
cent). The remainder of the program mainly
covers the control of communicable diseases.
The fellowship program is by far the best means
of reinforcing public health services. It is also
a vivid illustration of international cooperation,
for it not only enables the fellows to perfect their
knowledge abroad but also brings specialists
from other continents to study the problems of
Africa and to take advantage of the experience
gained in this continent. Moreover, the fellow-
ship program also enables countries and territor-
ies of Africa to exchange specialists with other
continents. By the end of 1957, the WHO Re-
gional Office for Africa had awarded over 500 fel-
lowships in all fields. In 1955 alone, fellowships
allocated represented fifty-seven years of study.

Cooperation with other international agencies,
such as UNICEF, FAO, CCTA, and ICA has
helped immensely to develop better health in
Africa.

JUNE 1958

213

Public Health

in the Western Pacific

I. C. FANG, M.D.

Manila, I lie Philippines

The western pacific region embraces a ter-
ritory which covers 100° of latitude equally
on both sides of the equator and extends at its
widest part from 100° west longitude to 120°
east longitude. The countries and territories en-
compassed by this geographic division include
Australia (and its non-self-governing territories),
Brunei, Cambodia, China (Taiwan), the Feder-
ation of Malaya, Hong Kong, Japan, Korea, Laos,
Macau, New Zealand (and its island territories),
North Borneo, the Philippines, Sarawak, Singa-
pore, Timor, Viet-Nam, West New Guinea, the
French and British territories in the central
Pacific area, and the United States territories of
American Samoa, Guam, and the Pacific Islands
Trust Territory.

The Region embraces a variety of peoples with
different languages, customs, religions, and cul-
tural backgrounds and widely diverging degrees
of progress because of the varying degrees of
economic, cultural, and social development of
the countries themselves. When the WHO Re-
gional Office for the Western Pacific was form-
ally established in 1951, it was faced, therefore,
with a wide variation in the standards of public
health development. In some countries, health
services were firmly established. In others, mod-
ern concepts of health were just beginning to be
accepted, while, in the majority, emphasis had
been placed on curative rather than preventive
medicine.

The first task of the organization was to deter-
mine the most urgent needs of the Region as a
whole, a task which in the initial stage was not
always easy in view of the lack of basic data

i. c. fang is World Health Organization regional
director for the Western Pacific and is located in the
Regional Office at Manila, the Philippines.

available. In the early days, assistance to govern-
ments principally took the form of programs
aimed at the control of communicable diseases.
However, the basic aim behind all programs of
assistance— the need to strengthen national health
services— was never lost sight of, and education
and training facilities have been gradually in-
tensified with a view to combating the shortage
of trained medical, nursing, and auxiliary person-
nel which hampers the development of health
services and has a deterrent effect on program
implementation. The approach to work in this
field has been fluid, and the type of assistance
offered has been adjusted to the particular needs
and existing resources of the countries and terri-
tories in the area. Particular emphasis has been
placed on training within the Region, and Aus-
tralia and New Zealand have played an impor-
tant role in this aspect of the program, as they
are able to provide most of the training facilities
required by member governments. The regional
program of education and training is not, how-
ever, limited to the award of fellowships. In
Cambodia and Fiji, for instance, where special
categories of subprofessional health workers are
trained, WHO has assisted the governments in
raising the level of teaching activities through
the assignment of lecturers. In Singapore, the
University has been strengthened through the
assignment of lecturers in different fields of activ-
ity, while, in the Philippines, a very successful
exchange program has taken place between the
University of the Philippines and the Johns Hop-
kins School of Hygiene and Public Health, which
has also been supported by the Rockefeller
Foundation. Intercountry seminars have been
organized in the fields of environmental sanita-
tion, nursing, venereal-disease control, and health
education, and recent conferences included one

214

THE JOURNAL-LANCET

on social and preventive medicine, which was
attended by the deans and professors of univer-
sities in the region, and a public health confer-
ence and study tour visited Japan and China
(Taiwan). Such intercountry programs have
done much to develop kinship among health
officials in the region. Where before each country
worked in seclusion, there is now an ever-grow-
ing understanding of the problems which exist
in the different countries. There is a gradual
outflow and intake of scientific information,
knowledge is being pooled and made available to
all, and experiences are being shared.

Among the earliest activities of the Regional
Office directed toward the control of communi-
cable diseases were those undertaken in the fields
of malaria, yaws, and tuberculosis. A highlight
of the continuing fight against malaria is the ex-
pansion of national control programs into malaria
eradication campaigns. Technical assistance has
been provided to most countries in the Region,
and, at present, WHO advisory teams are assist-
ing the governments of Cambodia, North Born-
eo, and Sarawak. An example of an effective
malaria eradication program is to be found in
Taiwan, where recent assessment of the program
showed that malaria transmission had been inter-
rupted in most parts of the island. In 1951, be-
fore the program started, there were 1,200,000
cases of malaria, resulting in 12,000 deaths; in
1956, four years after the campaign started, there
were only 492 cases with no deaths reported. In
the Philippines, malaria has also ceased to be a
major public health problem in many of the
former hvperendemic areas, and efforts are now
aimed at eradication of the disease. There is no
doubt that the work done in this field has had
a tangible effect not only on the health of the
people but on the economic development in
many countries in the Region.

Yaws, which has persisted in a number of
countries over the years and which is a major
public health problem in some areas, is being
systematically attacked. Yaws endemic areas are
being drawn into a region-wide program. Eight
governments have been stimulated to establish
yaws control programs with assistance from
WHO and UNICEF, and several governments
of island territories have undertaken yaws pro-
jects on their own.

A significant trend, which WHO has encour-
aged, is the increasing emphasis on over-all tu-
berculosis control programs in which BCG will
be an integral part. Many countries now accept
the concept of tuberculosis as a public health
and not a clinical problem. With the award of
fellowships to train medical officers and nurses,

tuberculosis control services are being improved,
while modes of execution, methods, supplies and
equipment, and recording of results are being
standardized.

The incorporation of health education in many
WHO-assisted projects has been a major develop-
ment which has helped to shape a new philos-
ophy of health among the peoples of the Region,
and countries are now showing increasing in-
terest in this phase of public health work. In the
schistosomiasis control project in Leyte, Philip-
pines, the emphasis given to health education
and the importance attached to community par-
ticipation has done much to establish a firm
foundation for health work in the local popula-
tion.

Diseases susceptible to control by known en-
vironmental sanitation technics still constitute a
major problem. Every effort has therefore been
made to stimulate governments in defining ex-
isting sanitation problems and in formulating
short- and long-range plans for the incorporation
of environmental sanitation in their health activ-
ities. In China (Taiwan), Japan, and the Philip-
pines, pilot composting plants have been estab-
lished, and in an area where unsafe human fer-
tilizer is a menace to public health, this may yet
prove to be one very important contribution to-
ward the improvement of public health.

The provision of nursing services was another
problem which had to be faced by governments
in planning the reconstruction and expansion of
health services, as, in many countries, effective
services could not be established until profes-
sionally trained nurses, midwives, auxiliary nurs-
ing, and midwifery personnel were available.
Assistance in this field has been given to almost
everv country and territory in the Western
Pacific. New programs in basic nursing have
been established; the entrance requirements in
schools of nursing have been made higher; and
teaching methods have been improved and nurs-
ing education administration strengthened.

The need for improvement in the field of ma-
ternal and child health is very real in many parts
of the Region, especially in countries where a
high proportion of births is still attended by
untrained persons. In some countries, assistance
was required in dealing with specialized pro-
grams, while, in others, the first objective was to
improve the situation as far as maternal and
child health mortality was concerned. WHO has
aided the governments of Cambodia, China
(Taiwan), the Federation of Malaya, Japan, the
Philippines, and Viet-Nam by providing special-
ist advisers, doctors, nurses, or midwives who
have been assigned for periods varying from a

JUNE 1958

215

few weeks to several years. There are still many
needs unanswered. More well-trained pedia-
tricians are urgently needed; there is a dearth of
maternal and child health administrative units
at the national level; and nutritional problems
receive insufficient attention. However, a num-
ber of major problems are gradually being over-
come, and slow but steady progress is being
made.

The evaluation of projects has become an im-
portant regional activity within the last year. All
WHO-assisted projects are reviewed at regular
intervals in order to assess the progress made
and to decide whether a redefinition of the pro-
gram is required as a result of the developments
which have taken place. Such evaluations also
form the basis for expansion of existing projects
and the introduction of new ones. Evaluation
reports on completed projects are, provided the

government concerned agrees, distributed to
other member governments in the Region, in
order that all may benefit from the experience
gained.

Although work in the Western Pacific Region
covers many other fields of activity, it is only
possible to mention some of the major problems
which are receiving attention. Assistance is still
required in almost every field of public health
and much remains to be done. However, dur-
ing the past years, a common denominator
has developed among countries in the Region,
that is, an increased awareness of the need for
health work, and the acceptance by all that
“health is a state of complete physical, mental,
and social well-being and not merely the absence
of disease or infirmity.” This is a considerable
step forward in the fight to improve the health
, of the peoples of the world.

Nine Years in the Regional Office
of Southeast Asia

CHANDRA MAM, M.D.

\ew Delhi , India

The regional office for Southeast Asia, the
first Regional Office to be established by
WHO, was started in October 1948 with the first
session of its Regional Committee in New Delhi.
The original member states were Afghanistan,
Burma, Ceylon, India, Thailand, and 2 metro-
politan powers — France and Portugal — in re-
spect of their territories of Pondicherry and Goa.
Later, Indonesia, Nepal, and the United King-
dom joined in respect of the Maidive Islands,
making a total of 10 member states with a pop-
ulation of about 500 million.

All of the countries represented in the Re-
gional Committee were predominantly rural.
Eighty per cent of the population lived in rural
areas with extremely low living standards, often
bordering on almost bare subsistence. Public
health services in most of the countries in the
Region were poor in the few urban centers and

chandra mani is World Health Organization re-
gional director for Southeast Asia and is located in
the Regional Office at New Delhi, India.

were practically nonexistant in the rural areas.

Communicable diseases caused by widespread
unsanitary environment were prevalent. Malaria
was claiming around 100 million victims each
year, with about 1 million deaths. Also, serious
malnutrition was widespread, and the rate of
maternal and infant deaths was alarmingly high.
The health services were biased toward clinical
medicine, and there was an acute shortage of
technical personnel and essential resources.

Except for a few small areas, this was the gen-
eral picture in this Region.

The expansion of basic public health services
for these large populations was the responsibility
of the respective governments, and tremendous
resources were required.

WHO assistance in this Herculean task had to
be largely promotional and catalytic in nature.
Accordingly, a start was made with immediate
short-term programs, and the major WHO pro-
grams during the first two to three years con-
sisted of providing international teams, with
some supplies, to demonstrate the control of ma-

216

THE JOURNAL-LANCET

laria, tuberculosis, venereal diseases, yaws, and
filariasis. These teams advised and guided the work
of national teams whom they trained to take
over the work after withdrawal of the WHO staff.

Pilot activities were started almost simultane-
ously toward positive health. A beginning was
made with programs for improving maternal and
child health, which also took the form of dem-
onstration and training projects. From the out-
set, the training of counterpart physicians re-
ceived major attention. Nurses’ training started
very early. Even in 1949, 7 nurses were work-
ing with WHO demonstration teams, and soon
afterward auxiliary staffs and other technicians
were trained. The emphasis, however, in the
earlier years, remained on training local person-
nel to work with the WHO staff in particular
projects in small well-defined areas.

These and other field programs developed very
rapidly. The year 1949 saw 16 WHO-assisted
projects operated by a field staff of about 25
at a cost of about $340,000. In 1952, the pro-
gram jumped to an estimated expenditure of
over $4,000,000, including over $2,500,000 under
“Other Extra-Budgetary Funds,” which came
largely as supplies from UNICEF. It covered
55 projects and utilized a field staff of about
125. In 1956, about 120 projects were under-
taken with a field staff of 143 and a field bud-
get of $4,695,419, including $1,902,866 under
“Other Extra-Budgetary Funds.” The number of
fellowships, including those financed by UNI-
CEF funds, also rose from 46 in 1949 to 69 in
1952 and to 101 in 1956.

Altogether, in the first nine years, WHO in
Southeast Asia has assisted with 12 malaria con-
trol projects, 10 projects for the control of t>e-
nereal diseases and yaws, 21 for the control of
tuberculosis (including BCG vaccination), 21 for
the promotion of maternal and child health (fre-
quently combined with the training of nurses),
and with 24 additional nursing projects, as well
as with numerous programs in other fields.

The shortage of equipment and supplies formed
a major obstacle, but UNICEF joined hands
with the regional office from the very beginning
bv providing much-needed supplies and equip-
ment for the demonstration and training proj-
ects. Major achievements of WHO and UNICEF
were in the BCG campaigns against tuberculo-
sis, yaws programs, maternal and child health
projects, and assistance to hundreds of rural
health centers as well as the joint development
of a penicillin plant and a DDT plant in India.

From 1952 onward, as a result of experience
in the field, it became clear that the control of
communicable diseases needed to be developed

by means of nation-wide mass attacks, and dem-
onstration and training projects gradually gave
place to mass programs, such as those for BCG
vaccination, malaria control, and yaws control,
in all of which WHO assisted the nation-wide
efforts of the local health administrations.

By the middle of 1957, of 450 million people
exposed to malaria, 200 million had been pro-
tected. In the BCG campaign against tubercu-
losis, 112 million people had been tested and 38
million vaccinated.

In regard to yaws, by the end of 1956, of some
77 million persons living in endemic areas, 37
million had been examined and 5 million treated.

Pilot projects against plague, leprosy, and tra-
choma were the bases for large campaigns which
are also under way.

In some countries, the large-scale national pro-
grams for malaria control are on the verge of be-
coming eradication programs. The same should
eventually be possible for yaws. Venereal dis-
ease control projects are now being carried on
without international personnel. It is of interest
to note that today control of tuberculosis, which
is the most serious communicable disease of the
Region after malaria, is being attempted through
the development of domiciliary and ambulant
therapy with modern drugs. The large-scale iso-
lation of individual patients at institutions was
found completely beyond the financial and tech-
nical resources of the countries in this Region,
except in Ceylon. Similarly, in leprosy control,
the emphasis has shifted to active case-finding
and noninstitutional treatment.

The training of counterpart personnel alone
proved insufficient and had to be expanded to
assist in training the very large numbers of work-
ers required for mass programs. Simultaneously,
the promotion of maternal and child health serv-
ices led to the need for nurses, midwives, health
visitors, and nursing auxiliaries — training for
which WHO has given large-scale and increas-
ing assistance through teaching staffs and sup-
plies.

The regional director’s annual report in 1953
lists national courses that, with help from the
WHO staff, trained about 1,850 nurses, midwives,
and nursing auxiliaries during the year. Accord-
ing to his report in 1956, similar courses helped
to train 3,700 such workers. Substantial assist-
ance has also been given in developing, pro-
moting, and expanding nursing and midwifery
schools as well as in providing adequate field
experience for the trainees.

All these expanding programs also needed high-
ly qualified medical personnel in large numbers.
The number available was shockingly small; for

JUNE 1958

217

example, it is estimated that Afghanistan and
Indonesia had 1 doctor for about 60,000 peo-
ple; India, 1 to 6,000; and Thailand, 1 to 7,000.
Because of the scarcity of qualified teachers as
well as the expense of modern medical schools,
progress in this vital field has remained slow,
although there has been steady improvement
during the past two to three years.

WHO has assisted by providing professors to
set up various departments in medical schools
and to train counterpart staffs as well as by fur-
nishing teaching equipment and supplies. Some
help has also been given in tbe preparation and
translation of textbooks.

Recently, the regional office has particularly
promoted the establishment of full-time depart-
ments of preventive medicine and of pediatrics.
Owing to the lack of qualified teachers in pre-
ventive medicine, a special arrangement was
made with the Harvard School of Public Health
to train young national teachers in a specially
organized public health teachers’ course lasting
two years. In addition to the assistance given
to medical schools, an important project was de-
veloped jointly with UNICEF to expand and im-
prove the activities at the All-India Institute of
Ilvgiene and Public Health, Calcutta, to provide
training in general public health, maternal and
child health, public health nursing, sanitary en-
gineering, and health education.

In the past three years, WHO’s role has been
directed more and more toward these training
programs. In 1956, in addition to training coun-
terpart teams and organizing a very large num-
ber of training courses in different subjects, the
regional office assisted in conducting 40 refresher
courses for about 700 trainees consisting of med-
ical officers, nurses, technicians, sanitarians, and
other auxiliary workers.

Emphasis has also been shifting from individ-
ual communicable disease control toward meet-
ing the more basic needs of the Region — rural
health services, improvements in sanitation, and
health education — and toward integrating spe-
cialized programs into the general public health
services. During the same period, some coun-
tries of the Region, particularly India, have un-
dertaken very large national community devel-
opment programs. Assistance is being increas-
ingly provided to strengthen these projects, es-
pecially through the development of rural health
centers.

Governments recognize the need for reliable
vital and health statistics in the Region, for, even
today, 3 out of the 7 countries have no records
of birth and death rates. WHO has given some
assistance during the last few years to efforts *r

improve and also develop statistical services.

As the awareness of positive health has in-
creased among the populations and large
amounts of international and bilateral assistance
have become available, governments are being
compelled to expand their health services to the
utmost of their total resources. Quantity is very
often provided at the sacrifice of some quality,
and the lack of adequate supervision at all levels
has become a matter of grave concern.

Apart from WHO and UNICEF, other impor-
tant organizations have been working in the field
of health in Southeast Asia. Through the bilat-
eral program of the U.S.A., much public health
support has also been made available to this
Region, of which the assistance given to malaria
control and, more recently, malaria eradication
is the most noteworthy. A large number of fel-
lowships and a variety of experts as well as some
equipment and supplies have been provided
through Colombo Plan arrangements. The Rocke-
feller Foundation and the Ford Foundation have
also substantially aided in medical education
and training. With all these organizations, the
regional office has worked very closelv.

The most important achievements in the first
nine years of WHO assistance may be summar-
ized as follows:

1. Expansion of programs for the control of
major communicable diseases, their develop-
ment into mass programs, and their gradual in-
tegration into the coneurrentlv expanding gen-
eral public health services.

2. Tremendous strides in training personnel,
especially nursing personnel and health auxil-
iaries.

3. Emphasis placed on pediatrics, especiallv
pediatric education, as well as the promotion of
maternal and child health services, and — what
is more important — the integration of these spe-
cialized services into general public health.

4. Improvement of medical education gen-
erally.

5. The establishment of departments of pub-
lic health and preventive medicine and the in-
tegration of the teaching of preventive medicine
into the general curricula of medical schools.

6. Active promotion of vital and health sta-
tistics.

7. Promotion of health education by training
kev personnel and the demonstration of field
technics at the country level.

Perhaps the most important achievement of
all, however, has been the fact that the govern-
ments in this Region now look upon WHO as
their natural collaborator and partner in all ef-
forts to improve the national health services.

218

THE JOURNAL-LANCET

Public Health in the

Eastern Mediterranean

A. H. TABA, M.D.

Alexandria , Egypt

The Eastern Mediterranean Region of the
World Health Organization, which extends
from East Pakistan in the East to Tunisia in
the West and from Syria and Iran in the North
to Ethiopia and Sudan in the South, probably
contains about 180,000,000 people. It has, since
the beginning of time, been one of the major
crossroads of humanity. Remnants from the
earliest known civilizations are still being un-
covered in this Region. Monotheistic religion
came- from this area, and one has only to men-
tion the art of writing and the science of mathe-
matics to indicate how much the world is in-
debted to the Eastern Mediterranean Region.

For over one thousand years, a large section
of this Region was politically unified under the
Persian, Macedonian, and Roman empires. Dur-
ing the first six centuries after Christ, wide areas
were influenced by Christianity. Since that time,
the major influence has been Islamism, which
is, today, the greatest single factor in the gradual
unity of the Region. Probably 85 per cent of the
population are Moslems, about 5 per cent are
Christians of various denominations, and about
2 per cent are Jewish.

As a crossroad in world shipping, the area has
been greatly influenced bv western civilization.

The more well-to-do part of the population has
much the same birth and death rates, life expect-
ancy, and standards of housing and education
as do the population of the western countries,
but a large number of the people in the Region
continue to live in very much the same circum-
stances as they did centuries ago.

a. h. taba is World Health Organization regional
director for the Eastern Mediterranean and is located
in the Regional Office at Alexandria , Egypt.

Approximately 90 per cent of the entire Re-
gion is desert, and the difference between town,
country, and desert is very much more marked
than it is in other parts of the world. The des-
ert is not an entirely uninhabited waste but is
sparsely populated with nomadic groups who
use it as a grazing area for their flocks of sheep
and goats.

The urban population varies greatly from
country to country. It is estimated to be under
10 per cent of the total population in the Sudan
and the Arabian Peninsula, about 40 per cent of
the population in Lebanon, and perhaps 50 per
cent of the population in Israel. The nomadic
groups make up approximately one-third of the
population in the Arabian Peninsula but form a
very small percentage of the population in Egypt
and Lebanon.

For the most part, statistical data for this Re-
gion are inadequate and usually not reliable. Dur-
ing the last ten years, the birth and death rates
in the area have been rather high. The latter,
however, have begun to decrease. The rates of
natural increase in population are going up, part-
ly because of the decrease in general mortality,
particularly in infant and child mortality, but
also because of the increasing survival rates.

The main achievement of modern public health
methods in this Region has been in the control
of epidemic diseases. The majority of the coun-
tries have facilities for dealing with epidemics,
should they appear. However, the control of
communicable disease still constitutes a major
field of WHO assistance to the countries of the
Region. The village populations in most areas
are, however, still burdened by a combination
of such chronic diseases as trachoma, bilharzia-
sis, venereal disease, malaria, and hookworm.

JUNE 1958

219

Malaria eradication programs are being carried
out in Iran, Iraq, Lebanon, and Syria, with simi-
lar projects under way in Egypt, Israel, and Jor-
dan. The chief handicap in these programs is
still the lack of adequate administrative machin-
ery in some areas which hinders effective action
in the control of eradication procedures.

It is inevitable that emphasis must continue
to be placed on the control of these diseases.

More information is becoming available on
methods for mass control of some of the diseases.
Pilot projects for the treatment of communicable
eye disease have been carried out in Tunisia and
Egypt, and mass campaigns using the procedures
developed are beginning. Similar pilot projects
in the treatment of bilharziasis and the control
of the snail vectors are being carried on in Iraq,
Sudan, and Egypt. Methods for the prevention
of infestation of the snails in new irrigated areas
are receiving special attention.

In the Middle East, there is a basic and urgent
need not only for more trained doctors, nurses,
and public health officers but also for the devel-
opment of a medical and health corps dedicated
to rural services. The education and training
programs, therefore, have formed an important
element in the WHO activities in the Region
during the past years. Such programs as the
training school for health assistants at Gondar,
Ethiopia, and the training programs for auxiliary
nurses in operation at Bengazi and Tripolitania
in Libya will provide health personnel with ele-
mentary public health training able to meet the
specific needs of areas in which they will serve.

The need for more adequately trained per-
sonnel in all of the countries cannot be overem-
phasized.

Much effort and considerable success can be re-
ported on assistance to the member states in de-
veloping their own institutions for the education
and training of all types and levels of health per-
sonnel — professional, subprofessional, and aux-
iliary. The consequent trained personnel avail-
able for expanding public health efforts is an
essential support factor and, in most cases, a
primary limiting factor. A great deal of aid has
heen provided by WHO to assist in the organi-
zation of the professional education of public
health personnel. Professors of sanitary engi-
neering at the Lhiiversity of Alexandria, at the
Technion in Haifa, and at the College of En-
gineering in Baghdad and teachers in industrial
hygiene and teaching consultants in special sub-
jects assisting in the organization of a depart-
ment of occupational hygiene at the new High
Institute of Public Health in Alexandria are all

carrying out their work under WHO sponsor-
ship. In Beirut, Lebanon, a professor of virology
in the medical faculty of the French University
and a professor of health education in the School
of Public Health at the American University are
EMRO appointments, as are a lecturer in para-
sitology in Baghdad and a professor of physiol-
ogy at the Medical School in Karachi. In Ethio-
pia and Israel, surveys have been carried out and
projects involving special consultants on medical
education have been undertaken.

Because of the pressing need for professionally
trained personnel, the fellowship program of
WHO has received special attention. Approxi-
mately 10 per cent of our total expenditures have
been for fellowship assistance.

A special item of interest in this program is
the number of undergraduate fellowships for
'professional training in medicine, pharmacy, and
nursing that have been awarded. This is highly
important in assisting to build a cadre of pro-
fessional health workers, physicians, pharma-
cists, and nurses in countries which do not have
many such professionally trained persons among
their citizens and which, as yet, do not have the
training institutions. Action has been taken to
stimulate similar undergraduate training for en-
gineers, in order to increase the cadre of quali-
fied sanitary engineers who are so necessary to
a technically sound environmental sanitation
program.

There has been a growing awareness in the
countries of the Region of the importance of
public health programs as an integral part of
the national planning. Assistance in developing
long-term plans and strengthening the national
health administrations to carry out these plans
is a major function of WHO. This is being done
not only on a central and organizational basis
at the Ministry of Health level but also in the
field of provincial health administration and
rural health. The development of programs for
the purpose of distributing and improving health
services to the rural areas has increased accord-
ingly during the last five years.

Three main trends, therefore, can be seen in
the public health activities in the Eastern Medi-
terranean Region. The governments, with the
assistance of the international health agencies
are: ( 1 ) continuing to improve their services for
the control or eradication of the prominent de-
bilitating communicable diseases; (2) strength-
ening the national and local administrations and
organizations for providing health services; and
(3) extending and improving educational facili-
ties for medical and related personnel.

220

THE JOURNAL-LANCET

Public Health

in Europe

PAUL J. J. VAN DE CALSEYDE, M.D.

Copenhagen, Denmark

Ten years ago, Europe was still struggling to
overcome the immediate effects of the war.
Infant mortality was high; hospitals and teaching
institutions were in ruins. Many countries were
suffering from an acute shortage of health per-
sonnel. The normal flow of information across
national boundaries had virtually ceased, and
years were to elapse before the gaps in medical
knowledge would be filled in. Europe, which
had at one time been in the lead in communi-
cable diseases, psychiatry, radiology, and surgery,
for example, was now lagging far behind.

Many agencies, including WHO, threw their
weight into the battle to overcome the emer-
gency. Supplies and equipment, medical liter-
ature, teaching missions, and fellowships to
health workers for study abroad began to make
good the deficiencies. A very promising start was
made on international cooperation for health
throughout the Region.

However, it was not long before disruptive
forces were again to slow up international com-
munication. Not until last year did health work
in the Region as a whole receive fresh stimulus
when the USSR, Poland, Bulgaria, Roumania,
and Albania, to be followed this year by Czecho-
slovakia, again took up their work with WHO.

In the meantime, much had happened. Infant
death rates had dropped to below prewar levels;
some countries had achieved lower national rates
than any in the world. Tuberculosis death rates
had decreased sharply, in some countries by 40
to 60 per cent over a period of five years. Bovine
tuberculosis was eradicated in a few countries;

paul j. j. van de calseyde is World Health Organi-
zation regional director for Europe and is located in
the Regional Office at Copenhagen, Denmark.

in others, eradication was in sight. The 5-nation
Venereal Disease Commission of the Rhine, set
up to combat infection among the boatmen and
their families on the river, was disbanded at the
end of 1953 because the number of new cases
occurring among this population of about 50,000
had become negligible. There were additional
territories in which the number of annual deaths
from diphtheria had fallen to zero or could be
counted on one hand. A telling attack had been
made on trachoma, and mass campaigns against
the disease were gathering momentum in coun-
tries bordering the Mediterranean. Public health
services had been consolidated in all countries
in the Region, frequently with assistance from
UNICEF for mother and child health services.

Methods of international service had also
changed. With the passing of the postwar health
emergency and the necessity for relief work to
individual countries, efforts could be concen-
trated on public health problems common to a
number of countries. The provision of supplies
and materials was no longer a prominent fea-
ture of WHO’s activities; its services to individ-
ual countries were largely concentrated on pro-
fessional education. Intercountrv programs, in
which the resources of several countries are
pooled, had become characteristic of WHO’s
work in Europe. This meant a considerable sav-
ing of money and personnel, since, by this
method, it became possible to achieve results
simultaneously in several countries. Intercountry
meetings also provide opportunity for bringing
members of related professions together who
should form a team at home but too often work
in magnificent isolation.

The renewed participation of the countries
just mentioned has not been under way for long.

JUNE 1958

221

Two of these member states have already acted
as hosts to some of our intercountry meetings.
A small group of specialists met in Moscow last
year to discuss public health laboratory services
in Europe, and a large seminar attended by
physicians and veterinarians from 23 countries
convened in Warsaw for discussions and demon-
strations on prominent zoonoses and veterinary
public health. Later this year, public health
administrators and malariologists from countries
in southeastern Europe will meet in Bucharest in
order to coordinate national campaigns for mal-
aria eradication. It is the third year that such a
conference has been held, and, according to
present plans, three to five years should see the
end of malaria transmission in this area. Next
year, the Roumanian government is to act as
host to the Regional Committee for Europe. The
last twelve months, which also saw the Regional
Office for Europe move to its permanent home in
Copenhagen, have thus been highly significant
in furthering international health work through-
out the Region and augur well for the future.

Europe today would normally be regarded as
a region with some differences between countries
in health problems and health services but with
a similar high level of development, particularly
as regards the more industrialized countries. Its
health problems may well appear insignificant
beside the high infant mortality, the epidemic
scourges of yaws and malaria, or the low stand-
ards of environmental sanitation in some parts of
the world. Certainly there are differences, but
no country in the world, whatever its develop-
ment, is without important health problems.
Easily the most important in Europe is mental
illness. Taking England and Wales as an ex-
ample, we find that 40 per cent of the available
hospital beds are occupied by mentally ill or de-
ficient patients. In the region as a whole, the in-
cidence of mental illness appears fairly uniform
throughout, though countries with less extensive
services show lower prevalence rates. The lack
of personnel— child psychiatrists and psychiatric
nurses, for example— is one of the obstacles to
development. At the same time, medical and
public health practice need to be reorientated
toward preventing mental illness, and mental
health must be included in the training programs
of nonmedical workers, such as social workers,
teachers, and juvenile court judges, who can
make an important contribution in this field. In
most countries, after-care services for patients
discharged from mental hospitals are inadequate.
Again, much more could be done to ensure men-
tally subnormal persons a place in society.

The Regional Office has concerned itself with

these various questions, chieflv through inter-
country meetings and through its fellowship
program. In addition to concentrating on the
mental health of the child, it has worked on
problems of the adult population, notably al-
coholism. It was also able to contribute to work
on the mental health of refugees, of which there
are large numbers in Europe.

Some further examples will illustrate the con-
tribution an international agency can make to
health work among highly developed countries.

As infant mortality falls, deaths shortly before,
during, and after birth figure more prominently
in the annals of wasted life. Perinatal mortality
has shown very little change in recent years. In
many countries, considerably more than half of
the children who die in their first year, die in the
first week after birth, and almost as many infants
are stillborn as die during the entire first year of
life. While improved perinatal as well as de-
livery and newborn care will save many lives, a
very large proportion of perinatal deaths occur
from causes against which specific counteraction
cannot readily be taken as yet. Two intercountrv
meetings studied perinatal mortality and found
that intensified research is needed in which pri-
marily the obstetrician, the pediatrician, and the
pathologist should participate. The office is now
engaged in coordinating perinatal research in
The Netherlands, Ireland, and Sweden.

The intercountry approach has also been put
to use in combating childhood accidents, in de-
veloping industrial health services and public
health laboratory services, in training virologists,
and in studying the educational needs of the
nursing profession. Many developments in health
education can be traced to a European confer-
ence convened in 1953. The present rapid ex-
pansion of services for the rehabilitation of
handicapped children sprang from a number of
intercountrv programs organized during and
since 1950. National schemes for handicapped
children were subsequently supported in several
countries by WHO and UNICEF.

One of the earliest programs initiated by
WHO in Europe was a series of meetings de-
signed to bring leading sanitary engineers and
public health officers together on common prob-
lems. There have now been five meetings, fo-
cused usually on one major topic. Among topics
which have been studied, I would mention the
pressing European problem of ground and sur-
face water pollution now that pure water is in-
creasingly needed for domestic and industrial
uses. A discussion on sewage disposal from iso-
lated dwellings brought out some useful sug-
gested standards for the design and operation

222

THE JOURNAL-LANCET

of septic tanks. In an effort to improve profes-
sional communication, an international glossary
of sanitary engineering terms was published. A
great deal of effort was also devoted to the train-
ing and use of sanitary engineers, and the region
has undertaken a study of water standards and
water quality as part of a world-wide approach
to this subject. Recently, a large conference dis-
cussed air pollution, which must also be counted
a most pressing problem in Europe.

With the rapid development of the peaceful
uses of atomic energy and its by-products in
Europe, personnel trained in health physics is in-
creasingly needed. In arranging training courses
for engineers, chemists, and public health ad-
ministrators, the Regional Office has been for-
tunate in being able to work with the Oak
Ridge National Laboratory, Tennessee; the Unit-
ed Kingdom Atomic Energy Authority, Harwell,
England; the Centre d’Etudes Nueleaires, Paris;
and the Centre d’Etudes pour les Applications
de l’Energie Nucleaire, Mol, Belgium.

It is impossible to foresee the full effects of the
peaceful uses of nuclear energy in the next dec-
ade, but social change will certainly be stimu-
lated and new problems may well be brought
into man’s social and mental life. In the coming
years, Europe and its regional health office will
need to take a wide view of these changes.

Work in chronic diseases and the public health
aspects of the aging populations is increasing in

Europe. At present, the Regional Office is at-
tempting to sum up the many developments in
public health and medical care and to determine
how the accumulated knowledge on old age can
best be put to use. For the study of cardiac and
vascular diseases, some internationalization of re-
search, particularly epidemiologic research, is
considered necessary. A better understanding
of the role of nutrition in the onset of these dis-
eases may lead to far-reaching changes. An ob-
vious application would be, for example, in
hospital dietetics.

The hospital itself is today in a period of tran-
sition. From a center for sheltered medical care,
it is becoming a social unit with a new relation
to the community at large and is fulfilling new
functions within the medical profession. WHO
undoubtedly has a role to play here in bringing
members of related disciplines together inter-
nationally and in making training available, par-
ticularly for medicallv qualified hospital adminis-
trators.

The entire program of WHO in Europe is
much concerned with education and training,
primarily through an international fellowship
scheme in which, to date, over 3,200 awards have
been made. It is largely through individual fel-
lowships and the many training courses WHO
has organized in the Region that the more ex-
ploratory or theoretic part of our work is con-
solidated and translated into practice.

International Health
in the Americas

Ten Significant Years

FRED L. SOPER, M.D.

B ashington, I). C.

An outstanding development of the past dec-
ade in international health in the Americas
is the unification of the programs of the Pan

fred l. soper is World Health Organization regional
director for the Americas and is located in the Re-
gional Office at Washington, D. C. In 1947, he was
elected director of the Pan American Sanitary Bu-
reau, which is the executive body of the Pan Ameri-
can Sanitary Organization. The PASO re-elected
Dr. Soper in 1950 and 1954.

American and World Organizations. During the
life of the Health Section of the League of Na-
tions, its activities were independent of and to
some extent competing with those of the Pan
American Sanitary Bureau, the traditional health
organization of the Americas. The Constitution
of the World Health Organization, drawn up in
1946, fortunately provides for regional organiza-
tions in different geographic areas. In the in-
terim before this constitution became operative

JUNE 1958

223

in 1948, the twelfth Pan American Sanitary Con-
ference, held in Caracas in 1947, adopted a new
constitution for the Pan American Sanitary Or-
ganization, especially designed to permit the
PASO to serve as the regional organization of
WHO for the Western Hemisphere. The Consti-
tution of 1947 gives breadth and full continental
scope to Pan American health activities, pre-
viously limited to the 21 American Republics by
the Pan American Sanitary Code of 1924.

Under this constitution, France, The Nether-
lands, and the United Kingdom became active
participants in the PASO, and agreements were
signed with WHO in 1949 and with the Organi-
zation of American States in 1950, whereby the
PASO serves as the regional organization of
WHO and is recognized as a Specialized Organi-
zation of the OAS.

The tenth anniversary of the Constitution of
the PASO was commemorated in September
1957 by a special session of the Directing Coun-
cil in the Hall of the Americas at the Pan Ameri-
can Union in Washington. The secretary-general
of the OAS and the director-general of WHO
joined the director of the PASB at the commemo-
rative session in emphasizing the importance of
this unification of international health activities
in the Americas in a single program.

No one could have foreseen a decade ago
how indispensable the unity of the international
health program would become with the un-
anticipated rehabilitation of the concept of the
eradication of communicable diseases.

The initiation of regional eradication programs
in the Americas against ( 1 ) the Aedes aegypti
mosquito, the urban vector of yellow fever in
1947, (2) smallpox in 1950, (3) yaws in 1950,
and (4) malaria in 1950-1954, was followed by
adoption of the world eradication of malaria in
1955 as an official program of WHO, UNICEF,
and ICA (International Cooperation Administra-
tion of the United States Department of State).
Undoubtedly this is the most significant mile-
stone in international health since 1902, when
organized international cooperation began.

When Pasteur destroyed the concept of spon-
taneous generation of infectious disease, the con-
cept of eradication of the causative agents of
communicable diseases became inevitable. Ety-
mologically, the word “eradicate” comes from
the Latin and means to take out by the roots —
to extirpate. Prior to Pasteur, medicine used the
verb, “eradicate,” and the noun, “eradicative,” in
relation to disease in the individual patient.
Today the term “disease eradication” means the
complete elimination of all sources of infection
or infestation so that, even without all preventive

measures, the disease does not reappear. In
1888, Chapin, commenting on Koch’s discovery
of the tubercle bacillus, boldly declared, “There
is no theoretical reason why a purely contagious
disease like tuberculosis cannot be exterminated.
If we can prevent the spread of contagion at all,
we can prevent it entirely.” Similar visions of
liberating the human race from malaria, yellow
fever, hookworm, and other diseases have arisen
as the mechanisms of transmission of these dis-
eases have been found and methods of preven-
tion devised.

Ronald Ross showed mathematically that ma-
laria could be eradicated under certain condi-
tions. General Gorgas believed that yellow fever
coidd be “eradicted from the face of the earth
within a reasonable time and at a reasonable
- cost”; and the Rockefeller Sanitary Commission,
dedicated to the battle against hookworm dis-
ease in the USA, carried the term “eradication”
in its title.

Disappointment and frustration were the lot
of the early enthusiasts who dreamed of disease
eradication. Tuberculosis receded slowly in some
countries, not at all in others; the prevention of
malaria proved too costly for rural areas; the
campaign for the eradication of yellow fever
appeared promising for some years but was
doomed to failure from its inception because of
an unrecognized reservoir of infection in forest
animals; and, although hookworm disease de-
clined in many countries, hookworm infestation
remained widespread.

The difficulties and delays in eradication led
a whole generation of health workers to ignore
the possibilities of eradication programs and to
devote themselves to general health programs
with emphasis on the gradual concomitant re-
duction of the incidence of all preventable dis-
eases.

The rehabilitation of the “eradication” concept
in public health has been gradual over the past
twenty-five years. In 1933, it was shown that
the Aedes aegypti mosquito had been eradicated
from the principal ports of Brazil. Half a cen-
turv after Chapin’s youthful enthusiasm. Frost,
reviewing tuberculosis data in the United States,
concluded in 1936 that “Under present condi-
tions of human resistance and environment, the
tubercle bacillus is losing ground and the even-
tual eradication of tuberculosis requires only
that the present balance against it be main-
tained.”

The eradication of Anopheles gambiae in Bra-
zil in 1939 and 1940, at a time when this most
dangerous of African vectors of malaria had
become a serious threat to tropical and subtrop-

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ical America, served to dramatize the possibili-
ties of the eradication technic.

The eradication of malaria as a disease became
practicable when it was found that DDT and
other residual insecticides can effectively block
the transmission of malaria, without the eradi-
cation of the mosquito vector, and that the in-
terruption of transmission is followed by the
spontaneous disappearance of the disease within
a few years.

When it was demonstrated that a single dose
of penicillin could make an infectious case of
syphilis or yaws noninfectious, the eradication
of these diseases became an administrative rather
than a technical problem.

The production of desiccated smallpox vac-
cine, viable for long periods at tropical tempera-
tures, has greatly strengthened the position of
those who have so long insisted that smallpox
can be eradicated.

Even in the case of tuberculosis, the introduc-
tion of modern therapeutic measures has caused
such a remarkable drop, first, in death rates and,
now, in incidence, that Chapin’s dream of eradi-
cation is shaping into reality.

Today it is apparent that Chapin’s dictum, “If
we can prevent the spread of contagion at all,
we can prevent it entirely,” cannot be efficiently
applied to individual communities or limited
areas. The full rewards of eradication come only
when the threat of reinfection or reinfestation
has been eliminated. Not only must eradication
be complete within each country, but it must be
carried out on an ever-expanding front across the
frontiers of neighboring countries on a regional
and, eventually, a world-wide scale. Eradication,
when possible, is never an easy accomplishment
and is often especially difficult in countries in
which the particular objective of eradication
may not be highly important and, consequently,
of little interest to the national health authori-
ties. Eradication is expensive and may well be
beyond the financial capacity of some countries,
which is an obstacle that must be cleared as
part of the solution of a common threat. The
funds of many countries must often be pooled
in order to develop eradication programs of com-
mon interest. Such pooling of government funds
follows diverse channels. In the special case of
malaria eradication, this is done through the

regular funds of PASO and WHO, the Technical
Assistance Fund of the United Nations, UNICEF,
the International Cooperation Administration of
the USA, and the special malaria eradication
funds of the PASO and of WHO.

The stimulation of national eradication pro-
grams and the coordination of these programs
in regional and, eventually, global programs is
a task peculiarly suited to the organizational
structure of the PASO and its special relation-
ship with WHO.

None of the official continental eradication
programs of the PASO is complete, but suffi-
cient progress has been made in each to guar-
antee final success. The Aedes oegypti mosquito
has not been found recently in Aruba, Bermuda,
Bolivia, Brazil, British Guiana, Chile, Costa Rica,
Curasao, Ecuador, El Salvador, French Guiana,
Guatemala, Honduras, Nicaragua, Panama, Para-
guay, Peru, and Uruguay; these areas are prob-
ably free of infestation. The PASB is cooperat-
ing with the governments of Argentina, Colom-
bia, Cuba, the Dominican Republic, Haiti, Ja-
maica, Trinidad, and the other islands of the
Caribbean in campaigns for the eradication of
this urban vector of yellow fever.

Smallpox has apparently not occurred in North
and Central America, the islands of the Carib-
bean, Chile, Panama, or Peru since 1954. In
1957, only 7 political units in South America
reported cases of smallpox.

In Haiti, where yaws eradication began in
1950, yaws is at the vanishing point, and a final
search for cases is being made as part of a small-
pox vaccination program.

Malaria has been eradicated from the United
States and Chile and from large areas of Argen-
tina, Peru, and Venezuela. Since 1954, all of the
malarious countries of the Americas, with the
exception of one, have prepared for the trans-
formation of malaria control programs into ma-
laria eradication projects.

Important as is the emphasis on eradication,
the basic program of the PASO and WHO in
the Americas is the effort to ensure continued
progress in general public health activities in the
Americas. This can be accomplished by (1)
strengthening the fundamental health services
of member governments and ( 2 ) expanding ed-
ucation and training facilities for health workers.

JUNE 1958

225

The World Health Organization

Ten Years of Progress

H. VAN ZILE HYDE, M.D.
Washington, D.C.

During the past ten years, the World Health
Organization has emerged onto the world
medical scene as a force of major importance.
Its influence reaches farther and penetrates more
deeply than does its name. Even physicians
whose everyday work is affected in many ways
by WHO activities are not yet widely cognizant
of its program and its far-reaching influence. It
is pertinent, therefore, to examine the many areas
of its activities. They represent a highly signifi-
cant accomplishment in international living.

The activities of WHO can be examined un-
der two major headings: (1) its world-wide

technical services and (2) its technical assistance
to individual governments. They are different
but equally important in the progress of medi-
cine and the progress of mankind.

WORLD-WIDE TECHNICAL SERVICES

International biological standards. The purity
and potency of many therapeutic substances can
be determined only through biological proced-
ures for which arbitrary standards must be estab-
lished. Such standards have little meaning un-
less they are in general use. This requires agree-
ment on an international basis.

The first international biological standard, that
for diphtheria antitoxin, was adopted in 1922
by the Health Section of the League of Nations.
Nearly 70 standards have now been set by WHO,
including those for antibiotics, hormones, vita-
mins, sera, and toxoids. The preparation, custody,
and distribution of standard preparations as the
basis for comparative tests is focused in two
international centers— Copenhagen and London—
with participation by other laboratories through-
out the world, including the National Institutes
of Health of the Public Health Service.

The international units provided under this

h. van zile hyde is chief of the Division of Inter-
national Health. Bureau of State Services, Public
Health Service, United States Department of Health,
Education, and Welfare, Washington, D. C., and
United States representative on the Executive Board
of WHO.

program give physicians the world over assur-
ance that the dosages they prescribe have uni-
form strength no matter what the source.

The complete list of the international biologi-
cal standards set by WHO to date is as follows:

immunologic substances — Antigens : Old tuberculin;
Purified protein derivative of avian tuberculin; Purified
protein derivative of mammalian tuberculin; Tetanus tox-
oid; Diphtheria toxoid, plain; Diphtheria toxoid, ad-
sorbed; Schick-test toxin (diphtheria); Cholera antigen
( Inaba ) ; Cholera antigen ( Ogawa ) ; Cholera vaccine
(Inaba); Cholera vaccine (Ogawa); Cardiolipin; Leci-
thin (beef heart); Lecithin (egg); Antibodies: Tetanus
antitoxin; Diphtheria antitoxin; Diphtheria antitoxin for
flocculation test; Antidysentery serum (Shiga); Gas-
gangrene antitoxin ( perfringens ) (Clostridium welchii
type A antitoxin); Clostridium welchii (perfringens)
type B antitoxin; Clostridium welchii (perfringens) type
D antitoxin; Gas-gangrene antitoxin (vibrion septique);
Gas-gangrene antitoxin (oedematiens); Gas-gangrene anti-
toxin ( histolyticus ) ; Gas-gangrene antitoxin (Sordelli);
Staphylococcus a antitoxin; Scarlet fever Streptococcus
antitoxin; Swine erysipelas serum (anti-N); Antipneu-
mococcus serum ( type 1 and type 2 ) ; Anti-Brucella
abortus serum; Anti-Q-fever serum; Antirabies serum;
Anti-A blood-typing serum; Anti-B blood-typing serum;
Antityphoid serum ( provisional ) ; Cholera agglutinating
serum (Inaba); Cholera agglutinating serum (Ogawa);
Miscellaneous: Opacity reference preparation.

pharmacologic substancfs — Antibiotics: Penicillin;
Penicillin K; Streptomycin; Dihydrostreptomycin; Baci-
tracin; Chlortetracvcline; Polymyxin B; Oxytetracycline;
Hormones: Oxytocic, vasopressor, and antidiuretic sub-
stances (previously named: posterior pituitary lobe); Pro-
lactin; Thyrotrophin; Corticotrophin (previously named:
adrenocorticotrophic hormone); Grooth hormone; Serum
gonadotrophin; Chorionic gonadotrophin; Insulin; Hep-
arin; Vitamins, Enzymes: Vitamin Da; Hvaluronidase;
Miscellaneous: Digitalis; Neoarsphenamine; Sulfarsphen-
amine; Qxophenarsine; Mel B; MSb; Dimercaprol; Pro-
tamine.

International pharmacopoeia. The pharma-
cologic and related professions recognized long
ago the necessity for all countries to use uniform
standards and preparations for medicinal agents.
The work of achieving uniformity in description
and strength of drugs began with the First In-
ternational Congress of Pharmacy in 1865.

By the time WHO came into existence, some
40 countries had published pharmacopoeias.
These showed wide divergencies. Nomenclature

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THE JOURNAL-LANCET

varied, and proprietary names adopted in coun-
tries not bound by patent agreements added to
the confusion. This meant that a prescription
could be compounded of different drugs in
different countries, and that drugs acceptable in
one country coidd be rejected by importers in
another because of nonconformance to arbitrary
and frequently unrealistic standards. The task
before WHO was obvious and urgent.

The pharmaceutical profession and the drug
manufacturing industry have actively assisted in
the development of a pharmacopoeia which fills
the need for an international guide. The first
edition of the International Pharmacopoeia ap-
peared in two volumes in 1951 and 1955. It is
being widely adopted as a model for national
pharmacopoeias, thus helping to assure uniform-
ity of specifications for the same preparation in
different countries.

International reference centers. WHO has
established international reference centers to
facilitate research and testing. Some of these
centers prepare, maintain, and disseminate bio-
logical standards. Others collect, exchange, and
study strains of Salmonella, Shigella, and Escher-
ichia and the viruses of poliomyelitis and in-
fluenza. The International Blood Group Refer-
ence Laboratory in London types rare blood
groups and maintains standard sera for distri-
bution for testing purposes.

International laboratory network. The refer-
ence centers are only a part of WHO's network
of cooperating laboratories. There are 6 addi-
tional regional laboratories which help coordi-
nate research on polio and disseminate informa-
tion on its prevalence as well as a system of col-
laborating laboratories widely scattered through-
out the world which keep a constant vigil on
influenza.

The WHO Influenza Study Program is con-
sidered to be an effective weapon in limiting the
spread of this disease. It is designed to prevent
disastrous pandemics, such as that of 1918 to
1919, by keeping constant world-wide watch for
the appearance and spread of influenza and per-
mitting rapid identification of causative virus
strains and earlv production of effective vaccines.

The study program is focused in 2 centers— the
World Influenza Center at the National Institute
of Medical Research in London and the Inter-
national Influenza Center for the Americas at the
Communicable Disease Center of the Public
Health Service in Montgomery, Alabama. Both
centers collaborate to get an over-all world pic-
ture of influenza. Many national laboratories
cooperate with these two international centers.

In the Americas, 70 laboratories of state and
local health departments, universities, and pri-
vate organizations cooperate with the Intern-
ational Influenza Center for the Americas. Of
these, approximately 60 are in the United States.
Fifty-seven centers in 46 other countries cooper-
ate with the World Influenza Center. These
cooperating laboratories keep the centers posted
on new influenza outbreaks and on the progress
of vaccine research. They also send samples of
virus strains to the centers for study and identi-
fication.

There is also an Influenza Information Center
in Washington, D. C„ operated for WHO by the
Public Health Service to receive and disseminate
reports on influenza incidence and strain identi-
fication.

While influenza cannot yet be prevented, the
world is better armed through WHO to minimize
its incidence and effects. The recent epidemic
of influenza is an example of this. Through the
efforts of WHO and the cooperating laboratories
in countries first affected, information on mor-
bidity and mortality as well as on strain types
was available to workers in the United States in
time to permit the manufacture of ample supplies
of a protective vaccine.

In each of WHO’s 6 geographic regions, a
major laboratory is designated as the WHO
Regional Poliomyelitis Laboratory. It coordinates
the work of other cooperating laboratories in the
region. Through this program, poliomyelitis
strains are identified and exchanged, determin-
ations are made of the degree of immunity of
populations, and scarce materials needed for
tissue culture are procured and distributed. Ex-
pert groups meeting under WHO auspices evalu-
ated and reported favorably on the use in the
various countries of the Salk and related polio
vaccines.

JUNE 1958

227

WHO-sponsored programs have also been
evaluating the efficacy and production of tv-
phoid, smallpox, diphtheria, pertussis, and teta-
nus antigens.

International nomenclature. The number of
pharmaceutical products in daily medicinal use
has expanded rapidly, leading to problems of
assuring ready identification of a drug through-
out the world. A WHO program advises govern-
ments on acceptable generic and nonproprietary
names for drugs and asks that these names be
protected against use as trademarks. This makes
it possible for science, the professions, and in-
dustry over the world to use the same common
names for drugs with full understanding. The
names included must be pronounceable in sev-
eral languages and must not have been pre-emp-
ted by a product already trade-marked in any
of the 87 member countries. Thus far, about
200 nonproprietary names have been recom-
mended by WHO and accepted by many coun-
tries, including the United States, as the official
names for drugs.

Reporting of diseases and compilation of in-
ternational health statistics are facilitated by use
of a standard classification of diseases, injuries,
and causes of death developed by WHO.

The problem of reporting health statistics in-
ternationally was closely related to the establish-
ment of an international medical nomenclature.
Like the problem of a standard nomenclature,
the preparation of a uniform and methodical
classification of diseases has been the subject of
study and discussion for many years. Since the
nineteenth century, different groups have at-
tempted with varying degrees of success to arrive
at a classification which would make it possible
to enter all morbid conditions under a limited
number of headings and to supply quantitative
information on groups of cases.

Because WHO was charged with promoting
development of health statistics throughout the
world, it inherited the problem of assisting statis-
ticians in the preparation of a classification sys-
tem which would have world-wide applicability.
The outcome of WHO’s efforts is the Interna-
tional Statistical Classification of Diseases, In-
juries, and Causes of Death. This work, along
with rules for selection of the underlying cause
of death and special lists for tabulation of
statistics, was published in two volumes in 1950
and 1952. Through this publication, WHO has
made international comparability of health sta-
tistics possible.

Another method by which WHO attempts to
establish a standard language for physicians the

world over is by convening study groups on
specific diseases. Two such groups met last year.

A study group on Histologic Definitions of
Cancer Types met in June in Oslo to consider
organization of an international reference center
for the coordination of exchange of histopath-
ologic materials. The group recommended that
special laboratories should be asked to hold
reference collections of pathologic materials and
sections from the cancers in which they are
especially competent. These materials would be
made available to other institutions on request.
Exchange of these materials would help arrive
at more precise characterizations of the num-
erous cancer types.

In October, a group composed of 15 leading
heart specialists from 12 countries met in Wash-
ington, D. C., to consider the Classification of
Atherosclerotic Lesions. The group studied pro-
cedures for the processing and examination of
specimens, discussed a proposal for establish-
ment of regional centers to study specimens, and
discussed procedures to classify experimental
degenerative vascular lesions created in the
laboratory and their bearing on the classification
of atherosclerosis in man.

The group agreed upon standards for the clas-
sification of this pathologic process and recom-
mended that studies be made of the relationship
between atherosclerotic lesions and mortality
on unselected material. They further recom-
mended an international program based on es-
tablishment of an international center which will
obtain case materials from its own resources,
from regional and national centers, and from
other collaborating laboratories. When the work
of studying and defining the lesions has reached
a suitable stage, study sets composed of speci-
mens, slides, and descriptive materials will
be made up. This program should contribute
measurably to the solution of problems in clas-
sification of atherosclerotic lesions and lead to
general acceptance of a uniform nomenclature
to describe the intensity, type, and time of evo-
lution of lesions.

Epidemic control. World-wide reporting of
diseases and vital statistics is another important
technical service provided by WHO. By means
of an international communications network es-
tablished in 1948, outbreaks of quarantinable dis-
ease in any country are reported to WHO head-
quarters in Geneva. News of such outbreaks
is broadcast to public health authorities in all
countries, to ships at sea, and to seaports and
airports. Health authorities can immediately
apply appropriate quarantine measures to pre-

228

THE JOURNAL-LANCET

vent the national and international spread of
these diseases.

This world-wide medical intelligence system
has become increasingly important as air travel
brings the nations of the world closer together.

The International Sanitary Regulations adop-
ted by WHO in 1951 are another service which
touches the physician in his everyday practice.
The yellow form— International Certificate of
Vaccination— which physicians in all parts of the
world are asked to complete for persons going
abroad is one example of these regulations in
action.

Measures to promote the use of uniform quar-
antine procedures and to ensure world-wide
epidemiologic reporting are the outgrowth of the
oldest area of international discussion and co-
operation in health. Beginning in 1851, a series
of international sanitary conferences was held
which enabled nations to gradually approach
agreement on measures for disease reporting
and quarantine. Effective agreement, however,
depended upon scientific understanding of the
nature of disease and its transmission. By the
close of the nineteenth century, scientific know-
ledge of diseases and of measures for their con-
trol had reached a point where it was possible
for nations to agree on uniform quarantine meas-
ures and epidemiologic reporting.

The first effective comprehensive international
sanitary convention was drawn up in 1903 and
was amended and supplemented many times.
Through WHO, however, there is now a uniform
set of international quarantine measures which
replaces 13 earlier agreements. The regulations
set forth the maximum restrictions which may be
imposed. In so doing, they are designed to'
facilitate rather than hinder the flow of com-
merce and still provide essential protection.

Publications. WHO publishes several series of
documents which are of interest to everyone in
the health field. The principal scientific period-
ical of WHO is the Bulletin which contains origi-
nal articles on public health subjects of inter-
national significance. These articles generally are
studies of results of specific disease-control
methods or of the geographic distribution of
diseases or reports of specific subjects which are
made by expert consultants on behalf of WHO.
Such reports are designed to determine the pre-
sent state of knowledge and to provide a current
synthesis of such knowledge. Also included in
the Bulletin are laboratory studies on subjects
within the organization’s scope of interests,
such as environmental sanitation, brucellosis,
and trachoma, which enable laboratory workers

to adopt uniform methods and achieve compar-
able results.

WHO has established panels of experts in 36
separate specialties in the health fields:

Addiction producing drugs
Antibiotics

Biological standardization

Brucellosis

Cancer

Cholera

Chronic degenerative diseases
Dental health
Environmental sanitation
Health education of the public
Health laboratory methods
Health statistics
Insecticides

International pharmacopoeia and pharmaceutical
preparations

International quarantine

Leprosy

Malaria

Maternal and child health

Mental health

Nursing

Nutrition

Occupational health
Organization of medical care
Parasitic diseases
Plague

Professional and technical education of medical and
auxiliary personnel
Public-health administration
Rabies
Radiation
Rehabilitation
Trachoma
Tuberculosis

Venereal infections and treponematoses
Virus diseases
Yellow fever
Zoonoses

From these groups, expert committees are drawn
to study and report on specific problems. These
experts are internationally well-known in then-
own special fields, and their findings represent
a consensus of the latest and most reliable opin-
ion available on the respective subjects. The re-
ports of these committees comprise the Technical
Report Series. More than 140 Technical Reports
have been published, covering a wide range of
topics— School Health Services, Biologic Standard-
ization, Nutrition, Accidents in Childhood, Chem-
otherapy and Chemoprophylaxis in Tuberculosis
Control, Juvenile Epilepsy, and Insecticides.

WHO publishes a series of monographs which
are comprehensive, technical works dealing with
specific health problems. Examples of subjects
in the 35 monographs which have been published
are: The Rural Hospital, The Psychiatric Aspects
of Juvenile Delinquents, Milk Pasteurization, The
African Mind in Health and Disease, Advances
in the Control of Zoonoses, Poliomyelitis, Influ-
enza, and Experiment in Dental Care.

JUNE 1958

229

Fig. 1. Status of a WHO
antimalaria campaign
as of December 31, 1956

COUNTRIES

ARGENTINA
BOLIVIA
BRAZIL
CANADA
COLOM Bl A
COSTA RICA
CUBA
CHILE

DOMINICAN REP

ECUADOR

EL SALVADOR

GUATEMALA

HAITI

HONDURAS

MEXICO

NICARAGUA

PANAMA

PARAGUAY

PERU

UNITED STATES

URUGUAY

VENEZUELA

The Chronicle , published monthly in English,
Spanish, and French editions, contains informa-
tion on WHO and its principal activities as well
as summary reports of meetings of its expert
committees and other advisory groups.

The WHO Epidemiological and Vital Statis-
tics Report, published monthly in English and
French, contains vital statistics on births and
deaths, incidence of notifiable disease, and other
epidemiologic and demographic information.

The International Digest of Health Legislation,
published monthly in separate editions in Eng-
lish and French, is the only periodical devoted to
health legislation of international significance.
It summarizes in each issue the recent legislation
of significance in a particular field, such as nurs-
ing, communicable diseases in schools, mental
health, and tuberculosis.

TECHNICAL ASSISTANCE TO GOVERNMENTS

The primary objective of WHO in rendering
technical assistance to governments is to help
them build strong and effective indigenous health
services. During the year 1958, it is providing
assistance to more than 112 countries and terri-
tories.

In accordance with priorities agreed upon bv
the first World Health Assembly in 1948, WHO
has concentrated its greatest efforts on the con-
trol of communicable diseases and on problems
of wide social significance, such as maternal and
child health, nutrition, and environmental sani-
tation.

Malaria, tuberculosis, and the treponematoses
have been the objects of WHO’s most concen-
trated and most successful attacks. Ten years
ago, it was estimated that 300,000.000 persons

230

THE JOURNAL-LANCET

OTHER AREAS

DESIRADE.LES SAINTES.MARIEl
GAL ANTE, PETITE-TERRE.

ST BARTHELEMY, ST MARTIN
FRENCH GUIANA

GUADELOUPE

MARTINIQUE

ST PIERRE AND MIQUELON

NETH ANTILLESIARUBA
BONAIRE, CURACAO, SABA,

ST EUSTATIUS, ST MARTIN
SURINAM

BAHAMAS

BERMUDA

BRITISH GUIANA

BRITISH HONDURAS

CAYMANS, CAICOS, TURKS

COLONY OF WINDWARD ISLANDS
DOMINICA

GRENADA- CARRIACOU
ST LUCIA
ST VINCENT

TOBAGO

TRINIDAD

JAMAICA

PRESIDENCY OF LEEWARD IS
ANTIGUA- 8ARBUDA
BRITISH VIRGIN ISLANDS
MONTSERRAT, ST KITTS-
NEVIS- ANGUILLA

ALASKA

PANAMA CANAL ZONE
PUERTO RICO
U S VIRGIN ISLANDS

contracted malaria each year. According to the
latest available estimates, 200,000,000 persons
were afflicted by malaria in 1957.

Experience gained from control programs by
1955 and the increasing evidence of mosquito
resistance to insecticides inspired WHO to urge
countries to think in terms of eradication of
malaria rather than control. Todav, eradication
is practically achieved in 9 countries or territories
and far advanced in 7 others. Eradication pro-
grams are presently being carried out in 44
countries and are about to get under wav in 16
others. The status of malaria eradication in the
Americas at the end of 1956 is indicated in
figure 1.

Approximately 5,000,000 people die of tuber-
culosis each year, and millions more suffer its

weakening effects. The international attack on
tuberculosis by WHO and the United Nations
Children’s Fund (UNICEF) has included mass
BCG vaccine campaigns and programs aimed at
improved sanitation and nutrition. By the end
of 1957, 200,000,000 persons had been tested
and 80,000,000 had been vaccinated. WHO is
now beginning to provide assistance in establish-
ing pilot projects on the use of the new anti-
tubercular drugs in the domiciliary treatment of
the disease.

WHO-assisted programs have shown remark-
able residts in campaigns against the trepone-
matoses, the most dramatic of which are perhaps
the yaws eradication campaigns.

In 1950, it was found that a single injection
of penicillin could cure a high percentage of

JUNE 1958

231

cases of this disfiguring, disabling disease in as
little as ten days. So far, 55,000,000 persons have
been examined and 16,000,000 successfully treat-
ed in yaws eradication campaigns with the as-
sistance of WHO.

Education and training, . WHO recognized at
the start that health problems throughout the
world could be solved only if there were trained
personnel available for the tasks involved. Bv
the end of 1956, the organization had awarded a
total of 6,174 fellowships to recipients from 150
countries and territories in an attempt to meet
this need. Of this number, 65 per cent went to
physicians, 12 per cent to nurses, and 6 per cent
to sanitarians. The remaining 17 per cent went
to statisticians, health educators, physical ther-
apists, pharmacists, and veterinarians.

WHO assists local teaching institutions by pro-
viding international instructors in many disci-
plines in the health fields. These instructors, in
addition to their direct academic duties, help
acquire and organize teaching materials and
train local personnel to carry on the work.

Another service provided by WHO is the
compilation of essential information on medical
education. The data which have been published
in the World Directory of Medical Schools in-
clude a narrative description of medical educa-
tion in the country followed by a list of the in-
stitutions with the dates they were founded, the

number of students at the time the information
was solicited, the number of students admitted
and graduated yearly, and the number of teach-
ers. A similar directory of dental schools through-
out the world is being compiled and will be
published shortly.

Medical education was given additional sup-
port in 1952 when WHO and the World Medical
Association, which has official relationship with
WHO as an international nongovernmental or-
ganization, jointly sponsored the First World
Conference on Medical Education. The second
of these will be held in Chicago in 1959.

SUMMARY

WHO’s ten-year record is proof of what can be
done to relieve suffering and improve living
conditions through cooperative effort which suc-
cessfully surmounts geographic, cultural, and
political barriers. WHO can be justifiably proud
of its record on the occasion of its tenth anniver-
sary, not only because of its measurable ac-
complishments and contributions but also be-
cause through its efforts people of the world
have become aware of their health problems
and have learned of measures which can be
taken to solve them. The world is small. What
happens in Geneva affects every doctor in Min-
nesota and gives him better tools with which
to work and a better world in which to live.

The following is a recent statement by President Eisenhower in which he
wholeheartedly endorses the work of the World Health Organization.

“The people of the United States are proud to share in the work of the
World Health Organization and the related Food and Agriculture Organization.
These broad and constructive programs give promise of raising the social and
economic conditions of all peoples, a necessary prerequisite to the prosperity
and security of all nations.

232

THE JOURNAL-LANCET

International Cooperation in Public Health

Prior to the Establishment of the World Health Organization

o

FRANK G. BOUDREAU, M.D.

New York City

INTERNATIONAL COOPERATION does IlOt flourish

in wartime except between allies, and, dur-
ing World War II, the flow of work of the prin-
cipal international health agencies was reduced
to a mere trickle. These prewar precursor agen-
cies of WHO were the Pan American Sanitary
Bureau, Washington, D. C.; the International
Public Health Office, Paris; the Health Organiza-
tion of the League of Nations; and the Division
of Industrial Hygiene of the International Labor
Organization, Geneva, Switzerland.

Two new official international agencies were
established during wartime — the United Nations
Relief and Rehabilitation Administration and the
Food and Agriculture Organization of the United
Nations — each of them concerned with the pre-
vention of disease and maintenance of health.

The International Public Health Office has
now ceased to exist; its functions and assets have
been taken over by WHO. The Health Organi-
zation of the League of Nations has passed into
history, having pioneered, explored, and formu-
lated international health programs which fore-
shadowed almost every aspect of WHO’s present
activities. This organization deserves the major
credit for laving the foundations of FAO and
WHO.

UNRRA has also gone, leaving behind a rich
legacy of bold precedent on which new and
richer international health, social, and economic
programs might be based. The Pan American
Sanitary Bureau, while maintaining its own iden-
tity, has become the regional bureau of WHO
for the Americas and is now enjoying greatly

frank g. boudreau, president of the Milbank Mem-
orial Fund, New York City, was the 1957 recipient
of an Albert Lasker award of the American Public
Health Association. He had been a member of the
Health Section of the League of Nations and attend-
ed the first United Nations Conference on Relief and
Rehabilitation as a member of the respective secre-
tariats. In 1946, he was a United States delegate to
the Interiuitional Health Conference held in New
York City.

enlarged budgets and expanded programs. FAO,
offspring of the League of Nations’ campaign for
better nutrition throughout the world, is one of
the specialized agencies of the United Nations.
It is located in Rome, long the seat of the Inter-
national Institute of Agriculture.

All of these agencies were organized along
similar lines, and, with the exception of FAO,
all shared certain basic functions — to prevent
the introduction of infectious diseases into the
countries concerned and their spread between
these countries, to restrict quarantine measures
to the minimum compatible with safety, to col-
lect and distribute epidemiologic intelligence,
to act as consulting agencies to national health
administrations, to assist in raising the level of
national public health services, and to promote
liaison among them.

As to structure, all of these agencies were sub-
ject to the direction and control of their mem-
ber states meeting periodically in assembly or
conference. A smaller board, council, or gov-
erning body, which acted as an executive com-
mittee and met at more frequent intervals, pre-
pared the work for the conference or assembly
and acted for the assembly in the intervals be-
tween assembly sessions. Most important for the
evolution of international cooperation was the
creation of the secretariat, or civil service, com-
posed of men and women with professional
training and dedicated to the ideals of “one
world.’’ It was the League of Nations which
raised the value of the secretariat to its highest
level as an instrument for organizing and
strengthening the ties which bind the nations
together in peaceful pursuits.

When, in 1939, for the second time, the lights
began to go out all over Europe, farsighted
friends of international cooperation demanded
that something be done to save the technical
work of the League and International Labor
Organization, which continued to perform out-
standing work but were now threatened with
extinction. The problem was to conserve the

JUNE 1958

233

key personnel, which could only be done by
sheltering them in a country outside of the zone
of direct hostilities and providing them with the
work needed to maintain their skills and morale.
The International Labor Organization thereupon
took refuge in Montreal, Canada, and part of
the Financial and Economic Organization of the
League accepted the hospitality of Princeton
University.

PREWAR INTERNATIONAL HEALTH AGENCIES

The earliest of these agencies was the Pan Amer-
ican Sanitary Bureau, established in 1902 by the
first International Sanitary Conference of Amer-
ican States, not including Canada. The chief
function of PASB was to prepare a sanitary code
which would reflect progress in the knowledge
of disease causation, such as Finlay’s theory that
yellow fever was mosquito borne. After many
years of effort, the Sanitary Code was adopted
by the Pan American Sanitary Conference in
1924 and ratified bv all of the 21 republics.

The International Public Health Office (Office
international d’hygiene publique) was estab-
lished in 1909 with headquarters in Paris. Its
principal functions were the preparation, en-
forcement, and periodic revision of the inter-
national sanitary conventions: the major legal
instruments defining the measures of prevention
to be applied to airplanes, ships, trains, passen-
gers, and goods which crossed national frontiers,
in relation to plague, cholera, smallpox, typhus
fever, and yellow fever. The Office was sup-
ported by contributions from its members of
approximately $50,000 a year. Its work during
the first and second world wars was seriouslv
interrupted, and, in recent years, its functions
and assets have been taken over by WHO.

Most important of official international health
sendees before World War II was the Health
Organization of the League of Nations, consist-
ing of an Advisory Council; a Health Committee
of a dozen members, some of them heads of lead-
ing health administrations, and others who were
experts in their own right; and the Health Sec-
tion of the Secretariat of the League, made up
of some 15 medical officers. The mandate of the
Health Organization consisted of a few words
in the League’s charter, calling upon member
states to take action in matters of international
concern for the prevention of disease.

The Health Organization possessed a number
of unique advantages which permitted it to de-
velop rapidly and to create useful precedents
for the future. It was established at a time when
Europe was faced with the threat of being over-
run by massive epidemics of cholera, dysentery,

and typhus fever from Eastern Europe and was
saved by an Epidemic Commission which the
League Council had set up on a temporary basis.

Previously, communication between national
health services had always been by way of the
foreign offices. It is not difficult to imagine to
what extent the utility of such communications
was lost by long delays. The very brevity of the
Health Organization’s mandate gave it freedom
to pioneer and experiment, and it benefited
greatly by being part of the most complete in-
ternational organization that had yet existed.
The Organization’s activities in health were sup-
plemented by other League bodies concerned
with social affairs, finance, economics, transpor-
tation, communications, and the health and wel-
fare of labor. Possibly its greatest advantage was
that the Organization, like the League itself in
the aftermath of the most destructive war in
history, appealed to the generous instincts and
aspirations of mankind and was confronted bv
tasks which its member states could solve onlv
by unprecedented cooperation.

As a result of these and other advantages,
the Health Organization took precedent-making
steps in the following fields:

1. The establishment of a world-wide system
of epidemiologic intelligence which, for the first
time in history, worked rapidly and accurately
enough to be of real service in the prevention
of disease.

Notifications of the existence of epidemic dis-
ease came in by telegraph and radio; they were
broadcast in code and in clear by a number of
radio stations so that news of infected ports and
territories coidd travel from countrv to countrv
and from port to port even more rapidly than
the spread of disease.

2. The founding of a technical assistance pro-
gram to underdeveloped countries which, to-

234

THE JOURNAL-LANCET

getlier with other sections and organizations of
the League, helped governments in the preven-
tion of epidemics; resettlement of refugees; pro-
vision of housing, seeds, agricultural implements,
clothing, food, and medical supplies; construc-
tion of roads and railways; and, ultimately, the
establishment of medical schools, research cen-
ters, and schools of public health.

The League’s efforts in technical assistance
began in such countries as Bulgaria, China, and
Greece and extended from assistance in stamp-
ing out disease to systems which included all of
the measures mentioned above as well as port
quarantine, hospital administration, and flood
control.

At one time there were some two score League
experts in China, including nationals from many
countries loaned to the League for service in
China and reporting to a National Economic
Council set up by the government of China for
collaboration with the League in its own national
reconstruction. At the moment when this tech-
nical assistance was at its height, the Sino-Japa-
nese War began with the Manchurian Incident
and was followed by the outbreak of World
War II, which brought the peaceful reconstruc-
tion to a halt.

3. Initiation of work in a series of health fields,
such as international standardization of biologi-
cals, organization of international courses in pub-
lic health and malariology, awarding of fellow-
ships to train personnel for national health serv-
ices, organization of collective study tours, prepa-
ration and conduct of international conferences
on rural hygiene, and the like.

4. The establishment of the first regional
health bureau, which became the League’s East-'
ern Bureau of Epidemiologic Intelligence at
Singapore.

INTERNATIONAL LABOR ORGANIZATION

Although not primarily a health agency, the In-
ternational Labor Organization had as its ob-
jective the health and welfare of labor. Its chief
characteristic was the representation of govern-
ment, labor, and management in national dele-
gations to the International Labor Conference
and in the composition of its governing body.
Vigorous and courageous leadership enabled the
ILO to grow rapidly in size and prestige; its
secretariat was second only to that of the League
in numbers and was known for its professional
competence. The ILO performed its work by
means of declarations, recommendations, and
draft conventions. Its preliminary studies and
investigations were frequently of outstanding
merit. Members of the organization were bound

to submit its draft conventions to their parlia-
mentary bodies for ratification. At present, as
in prewar days, ratification is a slow procedure
unless governments are spurred to action by
emergency situations.

After the United Nations was established, the
International Labor Organization became one of
its important specialized agencies, and, after war
ended, it was able to return to its own build-
ings on the shores of Lake Geneva. It is interest-
ing to remember that the United States became
a member of the ILO during the Roosevelt ad-
ministration, when Frances Perkins was Secre-
tary of Labor, before the U.N. was established.
The health of labor had always been an impor-
tant concern of the ILO, and this concern was
emphasized by the setting up of a Division of
Industrial Hvgiene in 1926.

INTERNATIONAL AGENCIES CONCERNED

WITH HEALTH ESTABLISHED DURING THE WAR

All that had been done in international health
cooperation before World War II was overshad-
owed when the Relief and Rehabilitation Ad-
ministration was set up by the U.N. to restore
and rehabilitate nations which had suffered oc-
cupation or devastation.

UNRRA’s Health Division was established in
December 1943. Together with the Division of
Medical and Sanitation Supplies it constituted
the largest international health service in his-
tory. Approximately $170,000,000 were expend-
ed by these divisions during the three years of
their operation. This is in contrast with the sum
of less than $500,000 expended by the Health
Organization of the League of Nations in its
best financial year. The largest proportion of
UNRRA’s expenditures for health purposes went
for medical and sanitation supplies, but about
$22,000,000 were spent for health activities
roughly comparable to those of a pre-war inter-
national health organization.1 Sawyer2 presented
an excellent account of UNRRA’s health work
in the American Journal of Public Health.

UNRRA, being a temporary agency, turned
over to the Interim Commission of WHO the
sum of $1,500,000 to enable the Commission to
complete some of its projects, including fellow-
ships, work in tuberculosis and malaria, and
missions of experts to countries with special
needs. The broad scope of UNRRA’s work and
the precedents it created by its imaginative ap-
proach to world health problems enabled WHO
to begin its work on a higher level than had
ever been possible before in history.

The establishment of the Food and Agricul-
ture Organization of the U.N. came as the direct

JUNE 1958

235

result of international conferences held in Hot
Springs, Virginia, in 1943 and in Quebec in
1945. Less directly, the origin of FAO goes back
to the middle 1930’s when the Health Organiza-
tion of the League, which had long been con-
cerned with human nutrition, was joined bv
other League sections and organs, including the
ILO, in a campaign to combat the world-wide
economic depression and the human misery and
privation which it was causing in so many coun-
tries. Lord Bruce of Melbourne, a member of
the League’s Council, proposed the “marriage of
health and agriculture” to emphasize the need
for greater production and better distribution
of food to restore and maintain human health
which, in many parts of the world, was threat-
ened by undernutrition and malnutrition while
surplus food products were piling up.

Member states of the League joined in this
campaign with enthusiasm. Surveys of nutri-
tional status were undertaken in many countries,
and the public began to see the folly of destroy-
ing food surpluses while the unemployed could
not obtain the food they needed for health.

When war broke out, an informal group in
Washington, D.C., which had been associated
with the League’s nutrition campaign, decided
to keep the movement alive. The late F. L.
McDougall, economic adviser to Lord Bruce,
was invited to join the group, and he interpreted
their ideas in a brief memorandum which in-
duced President Roosevelt to issue the call for
the first general conference of the United Na-
tions in wartime held at Hot Springs in 1943.
That conference created an Interim Commission
to prepare for the establishment of FAO in 1945
with Lord Bcyd-Orr of Brechin as its first Di-
rector-General. First located in Washington,
D. C., it has moved its headquarters to Rome,
long the site of the International Institute of
Agriculture, which it has absorbed.

Thanks to the initial impulse given to the
movement by Lord Bruce, Frank McDougall,
Lord Boyd-Orr, and the Health Organization of
the League, the emphasis in FAO’s program is
on food for health; its surveys of food consump-
tion have developed in accuracy and world cov-

erage. Its activities in the field of health through
better nutrition entitle it to a place among the
agencies concerned with world health both be-
fore and after the establishment of WHO.

SUMMARY

While modern war does not provide favorable
conditions for cooperation among the nations on
a world scale, the struggle to survive in World
War II forced the United Nations to resort to
unprecedented forms of collaboration, disregard-
ing in the process certain ancient national rights
and privileges which had long hampered the
growth of international agencies. Some of these
forms of collaboration did not survive the war.
However, statesmen who looked to the future
realized that when hostilities ceased, existing
international problems would not onlv persist
but would probably become more acute because
of rapid advances in science and technology.
Their views were reflected in the establishment
of the specialized international agencies already
mentioned as well as UNICEF, UNESCO, the
International Bank, the Monetary Fund, the
Economic and Social Commission, the central
organization of the United Nations itself, and
all of the international machinery now existing
or in preparation. For the war had shown that
such instruments must not onlv be able to ar-
rest the outbreak of hostilities but must also
be capable of organizing and strengthening the
ties which bind the nations together in peaceful
pursuits. The exploration, pioneering, and ex-
perimentation carried on during the first half of
this century by international health agencies,
profiting by the unprecedented advances in pre-
ventive medicine and public health in the last
twenty-five years, have blossomed into a more
complete international system for assisting gov-
ernments to prevent disease and to maintain
health than even the most optimistic might have
imagined possible in prewar days. Health has
led the way in teaching the lesson that, in the
long run, the approach to the prevention of war
must be positive rather than negative, for last-
ing peace may be achieved onlv by building it
into the hearts and minds of men.

REFERENCES

1. Boudreau, Frank G., M.D.: Quoted from article on Inter- 2. Sawyer, W. A.: Achievements of UNRRA as an International

national Health Organization, in Administrative Medicine. Health Organization. Am. J. Pub. Health. 37:41, 1947.

New York: Thomas Nelson & Sons, 1951, p. 438.

236

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Professional Education in WHO Programs

EDWARD GRZEGORZEWSKI, M.D.

Geneva, Switzerland

Looking at the work of WHO in different coun-
j tries and regions of the world, one can easily
observe that a considerable part of an organiza-
tion’s activities are essentially educational. Every
year about 1,000 fellowships and travel grants
are awarded for studies abroad, and their total
number from the begining of WHO work has
reached the 8,000 mark. Teaching staffs, assigned
by WHO on each country’s recpiest, work in
schools of medicine, public health, or nursing
in over 20 countries; in several others, they co-
operate in the training of auxiliary and ancillary
health workers. A number of courses and sem-
inars are assisted by WHO workers every year
in individual countries or organized as inter-
national training projects. For instance, in only
one region of Southeast Asia in 1956, over
3,700 nurses, midwives, and auxiliaries attend-
ed courses assisted by WHO personnel.

In Europe, where the individual countries re-
quest less direct assistance, preferring WHO to
facilitate the intercountry cooperation, two-
thirds of the WHO activities can be classified
as educational. They consist of international
courses, seminars, educational conferences, ex-
change of teaching personnel, and fellowships.

Besides such purely educational projects, many
other activities in all regions contain substantial
educational elements. Demonstration teams in
child health, tuberculosis, venereal diseases, ma-
laria, yaws, and so on have as one of their prin-
cipal objectives the training of their local coun-
terparts and as many local personnel as neces-
sary to continue successfully the work after the
international personnel have been withdrawn.

EDUCATIONAL OPPORTUNITIES

The imagination of many peoples and govern-
ments was captured after World War II by the

EDWARD grzegorzewski is director of the Division
of Education and Training Services of WHO and is
professor of preventive medicine and public health
at the University of Puerto Rico, S an Juan, and vis-
iting professor in public health administration at
Johns Hopkins University, Baltimore.

Author alone is responsible for the views expressed
in this article, which may or may not he those of the
World Health Organization.

progress in medicine and the health sciences
and by the potentialities of international co-
operation. These great expectations gave rise to
ambitious health programs in many areas which
seemed to forecast concentrated, vigorous, and
successful attacks on ill-health throughout the
world. However, it soon became evident that
there were many obstacles along the way. Two
of the most important ones required long and
patient educational action. One was the insuffi-
cient flow of medical and public health knowl-
edge between the countries and between the
linguistic and cultural groups of countries; the
other was the shortage of adequate professional
personnel for medical and health work in many
countries. To overcome these two obstacles, or
at least to reduce their importance, has become
the goal of the WHO educational program.

Experience with international work has shown
that lasting results in any branch of public health
can be achieved only if the program is based on
adequately trained and properly oriented local
personnel. The seriousness and size of the prob-
lem are evident from such figures as a ratio of
1 doctor to 60,000 persons in some countries in
Asia and Africa. Larger, but still very low, ratios
are found in many other countries. Similar short-
ages of trained nurses prevail in most countries,
and the shortage of sanitation personnel is per-
haps even more acute.

There are countries with no facilities for train-
ing any of these professional groups, and, in
some of them, there was not a single local per-
son qualified in any of these professions. Many
more countries lack facilities for specialized
training in some essential branches of public
health, medicine, or nursing. In view of this
situation, WHO decided to assist the countries
in the establishment and development of their
training institutions — advice is given on re-
quest on the organization of schools, curriculum,
and teaching methods; visiting teaching staffs
are sent with the main objectives of preparing
local teachers and establishing the teaching pro-
gram; and fellowships for study abroad for local
prospective teachers are offered. A few exam-
ples may show some of the various situations
WHO meets in different countries:

JUNE 1958

237

• hi Ethiopia where there is no medical school
and almost all doctors in the country are for-
eigners, a school was organized for health assist-
ants who could assume some elementary duties
in the rural areas. A few qualified young stu-
dents were sent on fellowships abroad to med-
ical schools with the view of forming on their
return a nucleus of the Ethiopian medical pro-
fession. The establishment of the school for
health assistants in Ethiopia is interesting be-
cause it is a joint project in which WHO co-
operates with the International Cooperation Ad-
ministration of the United States government
with the active participation of Ethiopian au-
thorities. Similar schools were assisted in Bur-
ma, Nepal, and Libya.

• In the countries of Eastern Mediterranean,
a great need was felt for an institution in which
senior nursing administrators and nursing edu-
cators could be trained. WHO assisted the gov-
ernment of Egvpt and the University of Alex-
andria in the establishment of the Regional
College of Nursing. Other countries of the re-
gion also cooperate in this venture. Many other
schools of nursing are assisted by WHO in sev-
eral countries on different levels of training —
basic, postbasic, and auxiliary.

• The University of Costa Rica wished to ex-
plore the possibility of establishing a medical
school and asked for WHO cooperation in the
form of consultation. Now the school has already
started to work through the national effort.

° Scandinavian countries, in spite of their high
standards of public health and of medical edu-
cation, wished to raise still higher the special-
ized training of their health officers but felt that
the teaching resources and the population of any
one of these countries were not quite adequate
for the purpose they envisaged. WHO assisted
in working out a program for all Scandinavian
training courses in public health and strength-
ened the teaching by bringing professors from
other areas. This program may gradually de-
velop into a Scandinavian School of Public
Health, into which the combined resources of
the participating countries can be pooled.

A great degree of flexibility has to be applied
in the educational program because the require-
ments and conditions of the various countries
differ considerably. WHO cannot limit its assist-
ance to a few types of programs and exclude
others equally needed. It has to find most suit-
able ways to meet the different needs of the
country as closely as possible. There was hardly
a profession in the health field for which WHO
had not made some arrangements for training
personnel, including senior public health offi-

DR. GRZEGORZEWSKI

cials; teaching staffs of professional schools on
postgraduate, undergraduate, and auxiliary lev-
els; medical and health ancillary personnel; and,
in some exceptional cases, even undergraduates.

The strengthening of national training re-
sources is, wherever possible, based on the coun-
try’s needs of health personnel and its training
potentialities. Availability of foreign resources
is also taken into account in this connection.

• Countries are encouraged and assisted in set-
ting up national study groups and holding con-
ferences on medical and related education; sev-
eral such studies have already been made in
Southeast Asia, Eastern Mediterranean, and some
parts of Latin America. In this respect, WHO,
having collected much information from all parts
of the world can assist countries 'with all this
information and impartial advice through its
multinational staff and consultants.

These examples illustrate only some fragments
of educational field work which gradually de-
veloped in all the six regions of the Organiza-
tion. It is accompanied by activities at the Ge-
neva headquarters which assist the regions in
the planning and development of their programs.
Here also the trends in professional education
are studied; ideas and methods potentially suit-
able for international work are explored; infor-
mation from countries is assembled, analyzed,
and put at the disposal of others; and organiza-
tion-wide programs are planned and coordinat-
ed. Liaison and cooperation are maintained with
other agencies and institutions interested in edu-
cation, such as UNESCO, World Universities
Association, and International Bureau of Edu-
cation, and in professional training, such as
World Medical Association, International Coun-
cil of Nurses, The Rockefeller Foundation, Kel-
logg Foundation, bilateral government agencies,
and many nongovernmental bodies. Some 50 in-

238

THE JOURNAL-LANCET

ternational scientific associations in all branches
of medicine joined the Council for International
Organizations of Medical Sciences, sponsored
jointly by UNESCO and WHO, in order to co-
ordinate seme activities in the exchange of sci-
entific information.

PROGRAM DEVELOPMENT

The educational program of WHO was and is
influenced in its substance and methods by a
number of circumstances:

1. The experiences of other agencies, such as the for-
mer health section of The League of Nations, the in-
ternational programs of the Rockefeller Foundation,
the Pan American Sanitary Bureau, and UNRRA.

2. Requests from the countries for advice and assist-
ance in training.

3. Advice from outside consultants, advisory panels,
and professional groups.

4. Results of WHO’s own studies and observations.
Subjects of particular interest or of program im-
portance are submitted to expert committees or
study groups who advise the organization on its
technical work. Among the educational subjects
discussed in this way were ( 1 ) teaching of pre-
ventive and community aspects of medicine; (2)
introduction of radiation medicine into medical
curriculum; (3) training of foreign postgraduate
students in public health schools abroad; (4)
postbasic nursing education; (5) health educa-
tion in medical, nursing, and related curricula;
(6) training of sanitary engineers; and (7) train-
ing of auxiliary health workers.

A considerable amount of information is usu-
ally collected in connection with these and other
educational meetings. Other information comes
from consultants and visiting teaching staffs and
from government and educational institutions.
Professional WHO staffs also conduct studies in
the various parts of the world. Part of this ma-
terial is published from time to time; some is
sent to governments on request, and some is
used in current work or awaits later utilization.

Exchange of scientific information through
carefully organized personal contacts aims at
keeping the teachers and key public-health ad-
ministrators abreast of the advancements in their
fields in other countries. Among various meth-
ods applied, the visiting teams of medical scien-
tists attracted particular interest. Composed of
scientists recruited on a wide international basis,
these temporary faculties worked on the average
of about one month each in over 20 universities
and arranged conferences on medical education
in 6 countries. Traveling international seminars
in public health were organized in 3 regions.
The number of international seminars or study

groups in the various health subjects usually ex-
ceeds 10, and sometimes reaches 20 a year. Some
of them refer to purely educational subjects —
like a series of world-wide and regional discus-
sions on the teaching of preventive medicine and
another on the teaching of pediatrics — others
provide for mutual education of the participants
in selected medical or public health subjects.

Travel grants and fellowships for advanced
studies give useful occasions for the exchange
of information and knowledge between health
workers. Hence, they are considered among the
most important educational activities in WHO.
Continuous effort is maintained to make this
activity as effective as possible through proper
selection and preparation of candidates and ju-
dicious placement in properly selected institu-
tions. A recent evaluation study of WHO fel-
lowships shows that the proportion of successful
studies and subsequent successful work on re-
turn exceeds 90 per cent.

Much of WHO educational work, and particu-
larly its fellowships, is based on the good will
of the cooperating countries and the over 1,000
institutions which accept WHO fellows, very
often without charge.

It is believed that the value of WHO educa-
tional programs consists not only in raising the
level of professional competence of health work-
ers throughout the world, but also in the ad-
vancement of international understanding and
the increase of faith in friendly international co-
operation for which education is perhaps one of
the best and most durable bridges.

The future of WHO educational work depends
on the means at its disposal — at present, some
one and a half million dollars a year may be con-
sidered spent for educational programs— and the
degree of cooperation it will enjoy from govern-
ment institutions and peoples of the world.

The main objectives of WHO programs in pro-
fessional education are:

1. To establish realistic national programs for
training health personnel in all countries,
based on their needs and conditions.

2. To assist in raising of professional educational
standards in all countries by developing na-
tional and regional institutions to levels com-
patible with the tasks of health personnel.

3. To strengthen further the international co-
operation so that the training and research
resources available in different countries may
be utilized most effectively in the interest of
health of all countries.

4. To search for still better forms of international
educational work.

JUNE 1958

239

Environmental Sanitation in a Global Setting

HERBERT M. BOSCH
Minneapolis, Minnesota

The Expert Committee on Environmental
Sanitation of the World Health Organiza-
tion has defined environmental sanitation as,
“The control of all those factors in man’s envi-
ronment which exercise or may exercise a dele-
terious effect on his physical, mental and social
well being.”

In one form or another, most of the problems
of control of the environment are still with us
in some parts of the world. They are as old as
that of providing a water supply for a small
village, as new as the disposal of atomic wastes,
as rural as the disposal of excreta from isolated
dwellings, and as urban as the problem of at-
mospheric pollution and the disposal of wastes
frem factories.

Even during the period it was operating under
an interim commission, WHO recognized the
importance of environmental sanitation. As a
matter of fact, the interim commission listed en-
vironmental sanitation as one of the “big six”
problems of world health along with malaria,
tuberculosis, venereal disease, nutrition, and ma-
ternal and child health. In February 1950, a
permanent Section on Environmental Sanitation
was set up within the Secretariat of WHO. This
Section obtained Division status on January 1,
1952.

WHO quite early recognized that environ-
mental sanitation is one of the components of
a balanced public health program and that work
in environmental sanitation is essential even in
campaigns against a number of specific diseases.
For example, the control and eradication of such
diseases as malaria, yellow fever, and bilharzia-
sis hinge upon control of environmental factors.
Tuberculosis control also has an environmental
phase. Certainly, adequate and safe water sup-
plies have been demonstrated to have profound
effects on the death rates of infants and young
children. With this in mind, the Fourth World

Herbert m. bosch is professor in the School of Pub-
lic Health at the University of Minnesota. He teas
the first director of WHO’s Environmental Sanita-
tion Program and has served on numerous occasions
as a WHO consultant.

Health Assembly in 1951 passed the following
resolution :

The Fourth World Health Assembly, recognizing the
supreme importance of providing, as an essential part
of the public health programme, for the improvement
of environmental hygiene and sanitation, including
the development on sound lines of urban and rural
planning and of housing schemes,

1. Recommends to all Member States that appropri-
ate provision should be made to train, and to employ
in their health administrations, adequate numbers of
public-health engineers, town-planners, architects and
other allied personnel;

2. Requests the Executive Board and the Director-
General to give to Member States all possible help in
creating the necessary training facilities.

In keeping with this as well as other resolu-
tions of the World Health Assembly and direc-
tives of the executive board, the program of en-
vironmental sanitation is a broad one. It is car-
ried on by both the central and regional offices
of WHO and includes the following:

1. The stimulation and promotion of sanita-
tion activities in individual countries with par-
ticular attention being given to building of an
administrative organization, training of sanitation
personnel, and dissemination of information.
Typical activities are provision of short- and
long-time consultants to governments at their
request; conduct of country demonstration and
teaching projects; and provision of technical
consultants on such subjects as insect control
studies, water treatment, sewerage design, indus-
trial waste disposal, and water pollution control.

2. Leadership, consultation, and coordination
in such fields as vector control; research on in-
sects’ resistance to insecticides; and promulga-
tion of standards of water quality, food sanita-
tion, atmospheric pollution, and radiologic health
protection.

3. Cooperation and liaison with the UN and
its specialized agencies as well as nongovern-
mental organization in environmental sanitation
fields.

In carrying on its program of environmental
sanitation, WHO from time to time calls on its

240

THE JOURNAL-LANCET

Expert Advisory Panel on Environmental Sani-
tation and its Expert Advisory Panel on Insecti-
cides.

MAGNITUDE OF THE TASK OF PROVIDING
A SAFE ENVIRONMENT

Provision and maintenance of a reasonably sat-
isfactory environment for the people of the world
is indeed a huge task. It is still unfortunately
true that perhaps three-fourths of the world’s
population use water supplies that are unsafe
and insufficient in quantity, dispose of excreta
and wastes dangerously, consume milk and food
which are subject to contamination, and live in
inadequate housing and are plagued by diseases
carried by insects and rodents.

In seeking solutions to the environmental sani-
tation problems of the world, WHO has encoun-
tered many difficulties. In many cases, failure to
find a solution does not lie in the lack of funda-
mental knowledge but rather in the absence of
methods applicable to a given situation. Almost
invariably, it is impossible to superimpose the
methods and technics of one culture on another
different culture. Methods which can be utilized
in the Western World may be totally unsatisfac-
tory in the Orient because of differences in cul-
ture, technical development, and economic re-
sources. The permanent solutions of the sanita-
tion needs in any country are those that utilize
to the maximum extent local materials and local
labor and which do not deviate too widely from
the established cultural pattern of that country.

An example is the problem of water supplies
which presents, indeed, a paradoxical situation.
There are undoubtedly a number of engineers
in the world who are capable of providing a
solution to the water-supply problem of any
large city of 100,000 or more population. How-
ever, a standard method of providing a safe
water supply for a village of 100 people in Africa
or Asia is not available. It is not that the meth-
ods used in the Western World would not be
satisfactory from a sanitary standpoint, it is that
such methods in most cases would not be eco-
nomically feasible. It is doubtful, for instance,
that it will ever be possible to import enough
hand pumps and well casings to provide the
types of small wells used in the United States
for all the villages of Africa. Local material and
labor must be used, and the best method of using
this material requires a high degree of technical
training and imagination. Perhaps, in such com-
munities, in countries which have no resources
in ferrous metals, the solution will be found in
the use of nonferrous products, such as vitrified
clay, cement, and asbestos.

THE PROBLEM OF COST

Cost is another problem which is always pres-
ent in connection with environmental sanitation
problems on a global basis. Environmental sani-
tation measures are cheap when they are meas-
ured in terms of per capita cost but, because
of huge numbers of people involved, are expen-
sive in terms of total cost. A safe water supply
will eradicate endemic cholera at a low per cap-
ita cost if measured over the entire life of the
water supply; nevertheless, it must be admitted
that the first cost of such a water supply is high.

Often forgotten is the fact that only a small
part of the cost of the water system should be
charged to disease prevention; the larger part of
the cost might well be charged to improvement
of the standard of living. In this regard, envi-
ronmental control differs from control of specific-
diseases by the administration of therapeutic-
substances. The cost of a smallpox vaccination
campaign can be charged only to disease pre-
vention. The use of a vaccine or an antibiotic
for the control of a specific disease has no ac-
companying side effect of raising the standard
of living, and, for that reason, direct cost com-
parison with environmental control methods are
not valid.

WHO is giving ever increasing thought to the
problems of financing of sanitation works. It is
imperative that these financing problems be
solved. Here, the sanitary scientist must join
with the economist and political scientist in seek-
ing a workable solution.

TRAINING OF SANITATION PERSONNEL

The greatest of all problems in the field of en-
vironmental sanitation is providing every coun-
try with a hard core of nationals of that country
who are competent in the public health aspects
of sanitary engineering. In this connection, the

JUNE 1958

241

Expert Committee on Environmental Sanitation
of WHO at its second session stated:

The assumption, perhaps too widely made, that under-
developed regions are not prepared for the services of
the best-trained specialists in environmental sanitation
can readily be contested. Countries of minimum re-
sources are most in need of the highest expert service
available, both for diagnosis of need and for planning
of solutions. The relegation of these functions to less-
adequately prepared persons results from a great mis-
understanding of the complexity of the problems in
environmental sanitation encountered in areas of low
economic level. These problems require for their solu-
tion the impact of high intelligence, training, and ex-
perience, even when the number of persons possessing
such qualifications is necessarily a minimum. It is un-
sound practice literally to send a boy to do a man’s job.

Unfortunately, the need for trained sanitation
personnel, such as sanitary engineers, is the
greatest in the areas which have the fewest re-
sources for training. The solution for this has
been to bring in international personnel with the
idea that they will work in the country until
sufficient national talent can be developed. A
moment’s reflection will indicate that this is at
best a stop-gap procedure. Ordinarily, interna-
tional personnel do not stay long enough to be-
come thoroughly acquainted with the language,
the problems, and the culture of the country in
which they are working. These personnel un-
doubtedly have a stimulating effect, but it is
almost axiomatic that the best solution to sani-
tation problems in any country will be devel-
oped only when technically trained nationals of
that country are available and willing to work
on these problems. Obviously, sanitary engineers,
just as members of other professions, are not
trained totally in a matter of a year or two. The
sanitary engineer must have basic training in
engineering before he can be trained into the
specialization of sanitary engineering just as an
epidemiologist must be first trained as a physi-
cian. Sending the very young man out of his
country for basic training has obvious disadvan-
tages, among which is the problem of picking
a lad of 17 or 18 years of age with some assur-
ance that he will be able to complete a five- or
six-year training program. Even more difficult
to predict is his willingness to return to work in
his native country after he has finished his train-
ing. Therefore, WHO as well as some of the bi-
lateral health organizations are giving primary
attention to developing national and regional
training centers. Here, the training is in institu-

tions operating under the specific economic, cul-
tural, and social conditions in which the trainee
will be working.

This is not to detract from the value of send-
ing well-selected individuals to foreign countries
for training. However, these individuals should
have received their first training in their own
country or, at least, in their own geographical re-
gion. Thev should be persons who give promise
of being able to exercise leadership roles either
in the health organization of their country or in
teaching institutes. Also, there is no implication
intended that establishing national training cen-
ters would eliminate the use of international per-
sonnel. Such personnel could be very well used
as consultants and teachers. From the standpoint
of promotion of international understanding, the
benefits of providing foreign training for selected
individuals and the use of international consult-
ants and teachers are very obvious.

ACCOMPLISHMENTS AND A LOOK AT
THE FUTURE

Although a recitation of WHO’s specific accom-
plishments in the field of sanitation will not be
included here, it should be noted that they have
been many and satisfying. WHO has assisted
more than 30 governments in the establishment
of environmental sanitation programs. At the
present time, there are more than 50 demonstra-
tion and training projects in operation. Ten uni-
versities have been assisted in providing sanita-
tion training. There has been a gratifying co-
ordination of efforts between WHO and other
agencies, such as UNICEF, the Colombo Plan,
and the health program of the International Co-
operation Administration of the United States
government. As would be expected, in the early
days of their development, these organizations
worked rather independently of each other. To-
day they recognize the need for close coopera-
tion in carrying on sanitation activities on a
global basis. Already preliminary plans have
been made by some of these organizations to
carry on a concerted water supply program after
the current malaria eradication program has
reached a successful conclusion. There is every
reason to believe that world-wide environmental
sanitation will continue to improve. This im-
provement not only will bring with it a reduc-
tion in communicable disease but also will result
in a better social and economic environment.

242

THE JOURNAL-LANCET

The Role of Health Education in Raising
Standards of World Health

JOHN BURTON, M.D.

London, England

In its appetite for discovery, for explanation,
and for making things work better, the rest-
less scientific tradition, like a rushing river, has
flooded the mysterious world of our ancestors
and spread a thin film of order over the pri-
meval forces which determined human behavior.
Like boatmen, scientists have paddled their little
canoes into the creeks and rivers of the world.
In the migration, many invisible islands have
been passed by, but others have appeared which
are too impenetrable for their fragile tools. Man
is one of these neglected islands.

In the pursuit of health and the conquest of dis-
ease, important progress has been made through
the application of chemical and physical knowl-
edge in the control of some grosser quantitative
aspects of morbidity. This has been accom-
plished through means largely outside the con-
trol of the individual. The future must concern
itself with the qualitative aspects of health and
the enjoyment of life. These can never be pro-
vided for people by experts. This is the situa-
tion that confronts us in comparing our present
condition with the state of complete physical,
mental, and social well-being proposed by the
World Health Organization in its constitution.

Where health education aims to give us a new
way of looking at this paradox is in its under-
lying purpose of releasing the immense human
resources in individuals and communities at
present enchained by ignorance, anxiety, and
fecklessness. Health education, to be of any sig-
nificance in the adult world, must bring inde-
pendence by cultivating an ability to choose.

Looking at such contemporary health prob-
lems as neurosis and mental health; the care of
children; accident prevention; nutrition; rehabili-

joh.v burton is medical director of the Central
Council for Health Education, London, England ; a
member of the WHO expert Advisory Panel on
Health Education of the Public ; and a member of
the editorial board of the International Journal of
Health Education, the official quarterly organ of the
Interrmtional Union for Health Education of the
Public, Paris, France.

tation of the aged, sick, and handicapped; and
environmental hygiene, it is indeed hard to see
how they can be tackled at all without cooper-
ation of a knowing, willing, and capable public.

At the root of all problems of education in
any culture are the relationships between the
people concerned. In fields such as health, tra-
dition characterizes the patient as passive and
dependent and the doctor as authoritative, om-
niscient, or even magical. Many every-day ex-
pressions reveal a mixture of fear or even dread
of doctors, and the word, “patient,” reveals an
attitude on the part of the professionals which
is significant. Economics and education are
changing the doctor— or nurse— patient relation-
ship in most parts of the world. That these
changes should be well understood and promote
an educational relationship is the onlv way of
making a virtue of this necessity. Because doc-
tors and nurses are likely to be the most numer-
ous professional workers and those to whom the
public naturally turns for the discussion of health
matters, the doctor— or nurse— patient relationship
is a first consideration for the future of health
education. As Kark and Naish have shown, there
is good evidence to indicate that when practi-
tioners of medicine sincerely believe that their
patients can help themselves, dramatic results
can be achieved. Similarly, where medical offi-
cers behave as if public health is public and not
the private concern of specialists in the health
department, remarkable interest and activity can
result. The main supports of dependency in the
relationships of those concerned are to be found
in the social differences between doctor and
patient, together with the lack of fundamental
health education in the public.

In this relationship, the medical profession is
only dimly aware that it is the patient and his
friends and relations who always make the first
diagnosis or recognize that anything is amiss.
As Koos has shown, it is they who decide wheth-
er they will consult a doctor or a quack, and
finally it is they and a whole complex of social
forces which determine whether they are willing

JUNE 1958

243

or able to carry on the treatment. How well the
patient makes these decisions determines the
effectiveness of Healtli Services, and the ability
to decide is determined by his educational state
and his attitude to medicine generally. In the
intimate clinical situation, only the doctor and
nurse, trained and aware of this aspect of their
work, are likelv to be effective. Where institu-
tions, such as hospitals or public health depart-
ments are concerned, a whole team of people is
involved, and it is becoming increasingly evident
that health workers specially trained in health
education can play an essential role in raising
the whole tenor of the relationship between
medicine and the public. From this point of
view, the future makes the dual demand for a
medical and nursing profession trained in the
attitudes and skills of health education and a
public sufficiently educated to obtain the maxi-
mum benefit from the technical ability of th*3
professional people. These developments put an
increasing strain on the meager resources of this
youthful profession.

Pari passu with its growing recognition, health
education itself has been undergoing a philo-
sophical revolution. The health propaganda of
yesteryear is giving way to the health education
of today. More and more is it recognized that
information and exhortations are not enough.
With totally inadequate financial resources for
research and evaluation, health educators have
been building up an eclectic discipline on the
findings of psychology, sociology, pedagogy, an-
thropology, and a variety of other crafts and
sciences. But the very powers which the intro-
duction of these new sciences puts in their hands
have dangers if the ethical position of the rela-
tionship with the public is unsound.

When professional people are convinced that
some health measure is of benefit, the tempta-
tion is strong to use means for getting it done
which may diminish the public’s sense of respon-
sibility and self-respect. The behavior sciences
put powers into our hands which greatly aug-
ment the possibility of influencing people to pur-
sue certain courses of action, and it is this which
introduces the ethical problem. There are many
ways in which authoritarianism can express itself
otherwise than by crude dictation, and one of
the dangers in the new technics derived from
psychology and anthropology is that the dictator
of yesterday can too easily become the manipu-
lator of tomorrow. The World Health Organiza-
tion, the tenth anniversary of which we are cele-
brating this year, has given a remarkable exam-
ple of how this difficult and vital ethical prob-
lem can be resolved. While firmly pursuing its

scientific policy, it has managed to avoid rigid
patterns and any semblance of doing for its
members what they should properly do for them-
selves. It has avoided both dictation and pater-
nalism, while, at the same time, giving a definite
lead. This has been achieved in the field of
health education by the calling of expert commit-
tees and regional conferences. The first regional
conference on Health Education held in London
in 1953 demonstrated to what extent the new at-
titude was already accepted. The report of the
first Expert Committee held in Paris in the same
year was of particular interest in that its philoso-
phy would clearly have been impossible ten
years earlier. In addition to these specific meet-
ings, health education has become an important
element in the deliberations of many other
WHO conferences and expert committees and
has thus taken its necessary part in the practical
deliberations of most aspects of health services.
Having laid the foundations broadly and firmlv
in the areas of major interest to the future of
world health, the Health Education section of
WHO has in its most recent meetings turned its
attention to the all important preparation of
specialists and to the training of doctors, nurses,
sanitarians, and others in health education.

If the flood of science is to be harnessed for
the benefit of man, we must put at least as much
energy and imagination into the human and bio-
logical sciences as we are so lavishly expending
on the physical and chemical.

With trained health education workers of high
integrity and a public capable of independent
and voluntary effort, the appalling time lag be-
tween discovery and recognition will be short-
ened and those inner resources of individuals
and groups which alone can enable them to man-
age their health affairs more wisely will be de-
veloped.

244

THE JOURNAL-LANCET

Nursing in World Health Programs

PEARL MGIVER, R.N.

New York Citv

The World Health Organization has given
nurses, who constitute the largest group of
health workers in most countries, great encour-
agement and support. In hospitals, public health
departments, and industrial or school health
services, there are few health programs which
can he carried out effectively without the par-
ticipation of competent nurses.

The number of qualified nurses in each coun-
try is usually influenced by ( 1 ) the status of
women in the country and the attitude toward
women who work outside of their homes, par-
ticularly if that work requires “the work with
one’s hands ”; (2) the availability of general edu-
cational facilities to both sexes and to all chil-
dren and youth regardless of their economic
status; (3) the availability of professional schools
of a high quality; and (4) the recognition of the
fact that good schools of nursing attract good
nursing students.

WHO was founded on the belief that “health
was not merely the absence of disease or disa-
bility. Therefore, the practitioners in all fields
of health service need a broad education which
prepares them not only to give physical care to
the sick, but also to prevent disease and disa-
bility, to promote both physical and mental
health, and to rehabilitate those who have been
sick and are disabled.

Nursing was recognized by WHO’s first di-
rector general as an essential component of the
health team, and, in 1949, a well-qualified Brit-
ish nurse, Miss Olive Baggally, was appointed
nurse consultant at the WHO headquarters in
Geneva. Her long experience as a chief nurse
with UNRRA and as executive secretary of the
Florence Nightingale International Foundation
made her an excellent choice for this important
post. Her responsibilities included developing
nurse training programs in countries where none

pearl mc iver is executive director of the American
Journal of Nursing Company, New York City. She
was formerly chief of the Division of Piddic Health
Nursing of the United States Public Health Service
and a 1955 recipient of a Lasker Award for out-
standing accomplishment. A graduate of the Univer-
sity of Minnesota, she received the Outstanding
Achievement Award from the University in 1950.

existed and working toward the improvement of
nursing education throughout the world.

Lyle Creelman of Canada, who served as Miss
Baggally ’s associate, became the chief of the nurs-
ing service in 1954 upon her retirement. At the
present time, an American, Elizabeth Hill, is Miss
Creelman’s associate in Geneva, and nursing con-
sultants are included as regular members of the
consultant staffs in each of the six regional of-
fices of WHO.

From the very beginning, nurses have been
members of WHO teams assigned to various
countries to develop maternal and child health
services, to help the national governments estab-
lish hospitals and health centers, and to organize
field services aimed at the eradication of disease
and the promotion of health. Of all the members
of the health team, nurses have the closest and
usually the most extensive contact with individ-
ual patients and their families. They are recog-
nized as the ones who translate scientific infor-
mation into simple language which the families
can understand and will accept, because, al-
though science has discovered new drugs and
vaccines which will prevent or control smallpox,
diphtheria, malaria, and other diseases, the value
of these health practices requires the intelligent
cooperation of individuals or families. In a
democratic societv, individuals have the right
to accept or reject health procedures which are
available to them. People tend to reject that
which they do not understand. Nurses serve as
the interpreters of new health practices and by
precept and example secure the cooperation of
the people.

It is recognized that good health services are
dependent upon the availability of competent
health practitioners. Therefore, the WHO nurses
have emphasized the establishment of schools
of nursing within member countries which will
prepare nurses for positions of leadership in
their own countries. Careful selection of good
students from the national schools for additional
study outside their own countries and assisting
them financially through the WHO Fellowship
program will also hasten the development of
nursing leaders in each country. Some of the
WHO nurse educators are assigned to organize

JUNE 1958

245

new schools, and, in the beginning, the entire
faculties may be WHO staff members. Their
aims are to develop their national counterparts
as rapidly as possible, turn over direct responsi-
bility for the school to them when they have the
essential qualifications, and then serve as sup-
porters and consultants to the national nurses
until they feel secure enough to take over. With
this accomplished, the WHO educators will be
withdrawn and may be reassigned to a new
project in some other country.

The delegates who attended the World Health
Assembly in 1954 recognized that nurses were
essential members of the health team. They de-
cided that they needed to know what the re-
sponsibilities of nurses were and what education
nurses needed to carry them out. Therefore, the
delegates voted to discuss the subject — Nurses:
Their Education and Their Role in Health Pro-
grams — at their Assembly meeting in 1956.

Nursing and health education members of the
WHO staff believed that the success of the pro-
posed discussion would depend upon the extent
to which nurses back home in the member coun-
tries discussed the subject prior to the scheduled
Technical Discussions in May of 1956. The big
question was, how could nurses throughout the
world be reached and encouraged to discuss the
subject widely and to formulate opinions and
recommendations for the consideration of the
delegates who were to attend the Ninth World
Health Assembly.

This problem was solved by calling upon the
two international nursing organizations which
had been brought into official relationship with
the WHO — the International Council of Nurses
with headquarters in London and the Interna-
tional Committee of Catholic Nurses and Med-
ical Social Workers with headquarters in Paris.
Both organizations were delighted to be of serv-
ice and agreed to urge their constituent national
associations to sponsor the preliminary discus-
sions within their countries. A simple discussion
guide was prepared and furnished to both or-
ganizations for distribution to all of their na-
tional constituents. Nurses responded enthusias-
tically. While the guides were prepared pri-
marily for nurses, in many countries the nurses
invited members of the other health professions
to participate in discussions. The discussion
guide suggested that the nurses in each country
summarize their opinions in answer to three
questions:

1. What is your present role in the health

programs of your country?

2. What role do you think you could or

should play in your country?

3. What changes in attitudes, educational
facilities, and so forth will have to occur be-
fore you can play the role you envision satis-
factorily?

Forty countries sent in comprehensive reports
in answer to these questions. The background
information prepared for the delegates was based
on these replies, and copies of all reports were
made available to the delegates for study during
the meeting. The interest of the delegates in the
1956 Technical Discussions was greater than at
any previous time. The 213 members of the dele-
gations who voluntarily signed up to partici-
pate in the 9 group discussions appeared to en-
joy the informality of group work and the op-
portunity to discuss the pros and cons of each
statement made.

No effort will be made here to review the
entire report. The complete report of the 1956
Technical Discussions was published in the July
1956 issue of the Chronical of the World Health
Organization. A summary also appears in the
October 1956 issue of the American Journal of
Nursing. The consultant staff was amazed at
the similarity of the conclusions reached by each
group. Although a number of diverse viewpoints
were expressed on such specific matters as
whether nurses should administer intravenous
injections upon a physician’s order, there was
general agreement with regard to five broad re-
sponsibilities which should be considered within
the scope of the nurse in any country. These
were :

1. Giving skilled nursing care to the sick and
disabled in accordance with the physical, emo-
tional, and spiritual needs of the patient, wheth-
er that care is given in hospitals, homes, schools,
or industries.

2. Serving as a health teacher or counselor to

246

THE JOURNAL-LANCET

patients and families in their homes, hospitals or
sanatoria, schools, or industries. Because of her
extensive and intimate contact with patients and
families, the nurse usually has the confidence of
the family and is in a strategic position to put
scientific information into simple language which
they will understand, accept, and put into prac-
tice.

3. Making accurate observations of physical
and emotional situations and conditions which
have a significant bearing on the health problem
and communicating those observations to other
members of the health team or other agencies
having responsibilities for that particular situa-
tion. Thus, the nurse is a very valuable liaison
between the patient and the physician, research
scientist, sanitarian, social worker, school teach-
er, or industrial foreman.

4. Selecting, training, and guiding auxiliary
personnel who are required to fulfill the nursing
service needs of the hospital or public health
agency. This also involves an evaluation of the
nursing needs of a particular patient and assign-
ing personnel in accordance with the needs of
that patient at a particular time.

5. Participating with other members of the
team in analyzing the health needs, determining
the services needed, and planning the construc-
tion of facilities and the equipment needed to
carry out those services effectively.

When considering the education of nurses, a
number of far-reaching conclusions were reached.
It was decided that the attitude of the public
toward the nursing profession must be improved
since that more than any single factor influences
the recruitment of competent students into the
nursing profession. The delegates added that the
public’s attitude may be influenced most by phy-
sicians who must show their respect for and con-
fidence in nurses. Several groups added that the
number of qualified nursing school applicants
increased as the educational program improved.

All groups agreed that the primary purpose
of a school of nursing was to provide a sound
education in nursing and not primarily to pro-
vide nursing service for a particular hospital
I even though clinical experience is an essential
part of professional education. They advocated
that, when possible, the school of nursing be ad-
ministered as a separate entity under a univer-
sity or other educational institution. They also
agreed that the director of the school should be

a qualified nurse skilled in teaching and familiar
with methods of educational administration.

In discussing the administration of nursing
services and the most effective utilization of
nursing personnel they said that, since in most
countries nurses comprise the largest number of
health personnel in either hospitals or health
agencies, there should be a chief nurse at local,
state, and national levels who is a member of the
administrative health team. While a physician
is usually the head of a multidisciplinary health
team, the chief nurse should participate on that
team in analyzing the health needs, planning
how to meet those needs, and suggesting the per-
sonnel and facilities required to provide the serv-
ices needed.

The delegates emphasized that there would be
teams of various kinds and levels of nurses with
a nurse for a leader. They suggested that the
same principles of democratic team relationships
pertain among the nurses and auxiliary workers
included on the nursing team as had been advo-
cated for the health team.

The importance of job analysis in nursing to be
sure that each worker was utilizing her knowl-
edge and skills effectively was advocated. They
urged that nurses develop workers with less
skill for those functions which do not require a
nurse’s education and training.

Shortage of personnel in remote or isolated
areas was recognized as a serious administration
problem. It was suggested that a system of
rotation be worked out for personnel assigned
to such areas, that comfortable living quarters
be available, and that additional compensation
be considered for hardship assignments.

Not all of these conclusions or recommenda-
tions can be fully carried out in most countries
immediately. The delegates recognized that these
were goals to be attained. However, progress is
already evident in many countries. Several coun-
tries have had or are planning to have discus-
sions on a national level similar to the one in
Geneva. At the Quadrennial Congress of the In-
ternational Council of Nurses last June, prac-
tically every paper given referred to some sec-
tion of this report. Never before has nursing
been discussed so thoroughly on an international
level bv a group of leading health administra-
tors, physicians, and nurses. WHO has given the
nurses of the world the encouragement and sup-
port which they have long needed and wanted.

JUNE 1958

247

Malaria Incidence in the World Todav

PAUL F. RUSSELL, M.D.

North Edgecomb, Maine

Six years ago, after considerable study, I esti-
mated that the number of malaria cases in
the world totaled about 350 million annually,
with 3.5 million deaths.1 Two years ago, another
careful look at the situation convinced me that
a likely estimate for the year 1955 would be
some 200 to 225 million cases throughout the
world, with 2.0 to 2.5 million deaths.2 Recently,
I made a third canvass of available data, which
is the basis of the following report.

Of course, it is realized that accurate vital
statistics are rare, especially from underdevel-
oped countries. Malaria, in particular, is subject
to much confusion. Sometimes, most fevers in
an area are classified as malarial, and frequently
many cases of malaria are not reported at all.
Rut, due to the increased emphasis on malaria
eradication during the past few years and with
wider and more detailed surveys by better
trained personnel, it is possible to present fig-
ures that probably are not misleading, although
they certainly cannot be considered as more
than estimates.

Using population data from the United Na-
tions Demographic Yearbook of 1956 and ma-
laria data from the World Health Organization
(WHO), the International Cooperation Admin-
istration (ICA), and the United Nations Inter-
national Children’s Educational Fund (UNI-
CEF), it seems likely that about 1.2 billion, or
44 per cent, of the world’s total population of
about 2.7 billion live in communities in which
they are now or have recently been exposed to
malaria infection. Of those living in endemic
areas, it is estimated that some 800 million are
receiving routine protection against malaria,
which leaves some 400 million not under routine
malaria control. Protection varies in quality in
different areas from relatively ineffective dis-
tribution of quinine in a few places to highly
satisfactory campaigns aimed at malaria eradi-
cation in many countries.

On the basis of data from WHO, it appears
that by the end of 1957, country-wide malaria

paul f. hussell is affiliated with the Rockefeller
Foundation, New York City, and is a member of
the World Health Organization Expert Advisory
Panel on Malaria Control.

eradication campaigns were in active operation
in areas with a total exposed population of some
247 million. To recapitulate, the world malaria
situation was probably something as follows at

the end of 1957:

Estimated total world population 2,677 million

Estimated total population

exposed to malaria 1,200

Estimated total population under

malaria eradication campaigns 247

Estimated total population under

less effective routine control 553 ”

Estimated total population without

routine protection 400 ”

How many cases of malaria occurred among
the 400 million who were without routine pro-
tection no one, of course, knows. One might, how-
ever, assume the same 29 per cent incidence rate
estimated by competent local observers to pre-
vail in India in the early 1930’s, when malaria
control was minimal in a country of some 350
million living under all sorts of climatic condi-
tions and degrees of malaria endemicity. If this
rate is assumed, one might expect some 116 mil-
lion cases of clinical malaria among the 400 mil-
lion unprotected peoples in 1957. There must
also have been a considerable incidence of the
disease among the 553 million who were poorlv
protected. Perhaps one might conservatively
assume a rate of 15 per cent. On the basis of
these assumptions and estimates, there was a
total of some 200 million cases of clinical ma-
laria in 1957, with the usual death rate of about
1 per cent.

As mentioned above, some 247 million of the
exposed population were under malaria eradica-
tion campaigns in 1957. It is worthy of note
that during 1958, new malaria eradication cam-
paigns are in operation to protect an additional
451 million.

Expressed in another way, of the world's total
of 197 nations, territories, dependencies, or ad-
ministered areas listed in the 1956 UN Demo-
graphic Yearbook, 63 are nonmalarious and 134
must be included in world-wide malaria eradi-
cation. Seventv now have such campaigns, so
that 64 remain to be encouraged to make eradi-
cation plans.

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THE JOURNAL-LANCET

Certain aspects of the present situation should
be mentioned. For example, very little informa-
tion about malaria has come out of Communist
China. Recently, Maegraith3 stated that the total
population in danger of contracting malaria to-
day is estimated to be “somewhere between 300
and 350 million.” He comments that “in many
areas antimalarial operations are already under
way, the detailed national plan for control was
finally settled only last year. The disease is to be
controlled over the whole country. The ultimate
aim is eradication, which is taken to mean what
it says in some regions and, in others, a reduc-
tion of transmission by mosquito control and
drug treatment to the point at which it becomes
and remains insignificant. This is to be achieved
by 1969.” Maegraith adds, “The progress of the
attack on malaria has so far been slow, largely
because the essential basic biological data has
taken so long to collect, but enough of this in-
formation is now available to allow the major
attack on the disease to develop. It is being
pushed forward with energy and devotion and
should have everv chance of success.

In the USSR over 4 million cases of malaria
occurred annually for several vears after World
War II. However, according to reports from
WHO, less than 10,000 cases a year are now
occurring, and, on the basis of control measures
now in force, no new infections are expected
after 1960. Albania, Bulgaria, Hungary, Poland,
Romania, and Yugoslavia have all attacked ma-
laria vigorously with a view to eradicating the
disease; all their exposed peoples are under good
protection.

In Asia, it is notable that Thailand, with 12
million in endemic areas, now has in full swing-
an eradication campaign that covers the coun-
try. It has been so successful that in areas of
some 4.3 million, active spraying has been dis-
continued and surveillance begun to find and to
destroy the last foci of the disease. Another note-
worthy point about Asia is that India, with some
360 million of its population living in endemic
areas, has in 1958 begun a malaria eradication
campaign after five years of excellent malaria
control which considerably reduced the inci-
dence of the disease. Taiwan and Ceylon are
both progressing notably in their malaria eradi-
cation campaigns and expect complete success
in the not too distant future.

In the Americas, the Pan American Sanitary
Organization (PASO) is sparking and guiding
a campaign that aims to eradicate malaria from
North and South America and the West Indies
in the foreseeable future. The objective has
already almost been reached in a number of

countries. In the United States, provisional data4
indicate that in a population of some 170 mil-
lion, the remarkably low number of 144 malaria
cases was reported to our National Office of Vital
Statistics in 1957. The Public Health Service has
surveyed 40 of these cases, confirming 24, of
which only 8 were found to represent infections
contracted within our borders — four in Califor-
nia and 4 in Oklahoma.

The stages of progress of the countries now
having malaria eradication campaigns follow:

I. Preparatory phase (14)

Egypt, Israel, Jordan, Southern Rhodesia, Swaziland,
Union of South Africa, Zanzibar, India, Brunei, Indo-
nesia, Laos, North Borneo, Sarawak, and South Vietnam.

II. Early attack phase (19)

Brazil, British Honduras, Costa Rica, Mexico, Panama,
Dominican Republic, Guadeloupe, Haiti, Bolivia, Colom-
bia, Paraguay, Peru, Madagascar, Iran, Iraq, Syria, Af-
ghanistan, Burma, and Cambodia.

III. Advanced attack phase (27)

Canal Zone, El Salvador, Guatemala, Honduras, Nica-
ragua, Jamaica, Leeward Islands, Martinique, Trinidad
and Tobago, Windward Islands, Argentina, British Gui-
ana, Ecuador, French Guiana, Surinam, Venezuela, Al-
bania, Bulgaria, Greece, Yugoslavia, USSR, Lebanon,
Turkey, Cevlon, Philippines, Thailand, and Taiwan.

IV. Consolidation phase (8)

USA, Puerto Rico, France (Corsica), Italy, The Neth-
erlands, Romania, Cyprus, and Gaza Strip.

V'. Maintenance phase (2)

Chile and Germany.

In conclusion, it should be stressed that the
great progress toward malaria eradication that
has been made during the past ten years has
been due in large measure to remarkable in-
ternational cooperation between WHO, PASO,
UNICEF, the United States Mutual Security
agencies, and governments of the 70 countries
that now have eradication campaigns.

WHO’s effective leadership has stimulated
nation-wide jirojects, demonstrated the feasibil-

JUNE 1958

249

itv of residual spraying, provided fellowships
and training courses, organized regional confer-
ences, fostered inter-country and inter-regional
unanimity, and financed basic research. PASO
itself and as the regional office of WHO for the
Americas has had a key role in the attack on
malaria in the New World.

UNICEF has had a tremendous impact on
malaria through its large appropriations which
have totaled no less than 26.4 million dollars
expended in some 56 countries from 1947 to 1957
under technical guidance of WHO. The 1958
malaria budget is approximately 8 million dol-
lars. The gains of the past few years would have
been impossible without this basic UNICEF
financial and moral support.

The United States, through ICA and its prede-
cessor agencies of the mutual security program,
has also had a vital part in the global malaria
eradication campaign. In addition to its rela-
tively large share of the budgets of WHO, UNI-
CEF, and PASO, the United States spent about
89 million dollars for malaria control and eradi-
cation from 1942 to 1957. The 1958 budget of
ICA for malaria eradication is 23,3 million dol-
lars.

Finally, it should be emphasized that approxi-
mately 60 per cent of the cost of malaria eradica-
tion campaigns is being borne by the countries
concerned. Great credit should go to the polit-
ical leaders of these countries for their support
of malaria eradication.

REFERENCES

1. Russell, P. F.: Malaria; Basic Principles Briefly Stated. Ox-

ford: Blackwell Scientific Publications, 1952.

2. Russell, P. F.: World-wide malaria distribution, prevalence,

and control. Am. J. Trop. Med. 5:937, 1956.

3. Maegraith, B.: Chinese are “liquidating” their disease prob-

lems. New Scientist, December 5, 1957.

4. Dunn, F. L.: Personal communication from Communicable

Diseases Center, Atlanta, Georgia, 1957.

As the first decade of tlie World Health Organization ends, it becomes ob-
vious that international collaboration in health has justified itself and that its
possibilities for the future are unlimited. Each vear, the countries of the world
are learning how to work together better for the common good. It has long
been recognized that disease knows no boundary; nations are now beginning
to realize that organization for health also has no boundary.

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International Aspects of Occupational Health

LEONARD J. GOLDWATER, M.D.

New York City

COOPERATION AMONG NATIONS ill the Control

of communicable diseases is an obvious ne-
cessity which grows in importance with each
new advance in methods of transportation. The
elaborate systems which have been developed
internationally to control the spread of living
agents of disease are well known, and their ef-
fectiveness has been proved over and over again.
When it comes to nonliving agents, such as
chemicals and physical forces, the reasons for
international cooperation are not so clear nor
does the motivation for international action
appear to be quite so strong. Contamination of
the earth’s atmosphere with radioactive materials
is, perhaps, an exception.

When we move outside the realm of chemical
and physical agents of disease into the larger
spheres of occupational health, such as medical
care for workers, workmen’s compensation, sick-
ness insurance, housing for workers, nutrition,
vocational rehabilitation, and the like, the rea-
sons for international efforts become quite neb-
ulous. If, however, we accept an International
Labor Organization declaration that “Poverty
anywhere constitutes a danger to prosperity ev-
erywhere,” the One World concept in occupa-
tional health takes on significant meaning, since
good occupational health leads to good industrial
production and this, in turn, to prosperity.

An important prerequisite to any international
health activity is the existence of relevant health
programs in a number of individual nations.

Interest in occupational health developed
earliest in those countries in Western Europe
which were the first to become industrialized,
particularly, France, Germany, Great Britain,
and Italv. A significant event with international
implications was the publication in 1700 of the
monumental work, De Morbis Artificum Dia-
triba, by Bernardino Ramazzini of Padua. The

Leonard j. goldwater is professor of occupational
medicine in the School of Public Health and Ad-
ministrative Medicine at Columbia University, New
York; a member of the Expert Advisory Panel on
Occupational Health of the World Health Organiza-
tion; and a member of the Correspondence Com-
mittee on Occupational Safety and Health of the
International Labor Office.

translation of this book into English, French,
and German during the early part of the eight-
eenth century showed that its value was rec-
ognized internationally, and it established a com-
mon international basis for an understanding of
occupational diseases. This, of course, antedated
the industrial revolution.

According to Teleky, the first attempts to
secure international agreements on labor protec-
tion were made by a Frenchman named Blanqui
in 1838. Similar efforts were made in 1840 by
Villerme of France and Luc Le Grand of Swit-
zerland. At a meeting in Geneva in 1866, the
International Labor Association recommended
the establishment of international codes for the
protection of the health of workers. Several
additional attempts along these lines were made
during the latter years of the nineteenth cen-
tury.

An International Congress for Labor Legisla-
tion was convened in Paris in 1900. An out-
growth of this meeting was the formation of the
International Association for Labor Legislation,
which had its first meeting in Basel in 1901. An
International Labor Office was established in
Basel in 1902, and this office began the publica-
tion of a bulletin dealing with labor legislation
and safety regulations. The International Labor
Office created a permanent Hygienic Council
in 1908. These two organizations played an im-
portant part in securing the almost world-wide
legislative controls which were imposed on the
use of white phosphorus in the match industry,
on the manufacture and use of white lead, and
on the night work of women.

During World War I, all international groups
suspended operations, but activity was resumed
shortly after the cessation of hostilities. The
present International Labor Organization (ILO)
was created in 1919, under the terms of the
Treaty of Versailles. The principles and pro-
cedures of this organization were stated in the
treaty to be “well fitted to guide the policy of
the League of Nations” in matters dealing with
labor and industrial health. Although ILO re-
ceived financial support from the League of
Nations, it was not set up as a subdivision of
the League. This meant that membership in the

JUNE 1958

251

organization was not contingent upon member-
ship in the League and that its decisions were
not subject to the control of the Council of the
League of Nations. This pattern made it pos-
sible for the United States to belong to ILO,
even though this country never became a mem-
ber of the League of Nations. ILO is the only in-
tergovernmental body set up after World War I
which has survived to the present time.

PRESENT ORGANIZATION AND ACTIVITIES
OF ILO

This specialized agency of the UN differs from
its sisters and brothers, WHO, FAO, UNESCO,
and others, in that its policy-making body con-
tains representatives not onlv of governments
but of labor and employers as well. Each of its
77 member countries sends 2 representatives of
government, 1 of labor and 1 of employers to
the International Labor Conference. These rep-
resentatives, in turn, elect 40 of their members
in the same 2:1:1 ratio to the governing body
which appoints the director general and is re-
sponsible for the work of the International Labor
Office. The latter is, in reality, the secretariat
of ILO, employing a large staff of experts to
carry out the principal functions of research,
education, and technical assistance in the broad
field of occupational health. Long-term and
short-term consultants are frequently engaged
to assist in carrying out special projects in all
parts of the world. An international expert ad-
visory group known as the Correspondence Com-
mittee on Industrial Hygiene has been organ-
ized to help when needed. Regional offices, mis-
sions, or agents have been established in some
50 countries.

International agreements to restrict the use
of white phosphorus, white lead, and night work
for women were the first of more than 100 “con-
ventions to be adopted by the International
Labor Conference of ILO. Nearly 90 of these
are now in force, and they have received about
1,500 ratifications among the member nations.
A ratifying nation agrees to be bound bv the
convention. Among the other conventions which
have received wide ratification are those con-
cerned with factory inspection, medical exam-
ination of young workers and seafarers, accident
prevention, and anthrax.

Another important activity of ILO has been
the development of what has become known as
the International Labor Code. This code em-
braces the various conventions and a number of
recommendations dealing with a wide range of
subjects relating directly or indirectly to occupa-
tional health.

I. .I mi

Space does not permit a full account or even
mention of all of the activities of ILO in its
programs of education and technical assistance.
Some of its publications are among the most
valuable in the fields of industrial hygiene and
industrial safety. ILO technical assistance has
been invaluable, particularly to those nations
which have recently begun to develop industries.

WORLD HEALTH ORGANIZATION

In many respects, the basic organization of
WHO is similar to that of ILO. The policy-
making body is the World Health Assembly from
which an executive board of 18 members from
18 participating states is elected. The major
functions are carried out by a secretariat with
headquarters in Geneva and 6 regional offices.
WHO began functioning on an interim basis in
1946, but its constitution was not formally rati-
fied until 1948. Its membership now embraces
about 90 nations. It is similar to most of the
specialized agencies of the UN in that its policy-
making body is made up entirely of representa-
tives of governments. In this respect, it differs
from ILO.

At the time of WHO’s creation, an authorita-
tive international body already existed (ILO)
operating in the field of occupational health.
For this reason, WHO did not immediately con-
cern itself with this type of work, and it was
not until 1950 that a section on Social and Oc-
cupational Health was established. It had been
recognized that although ILO's concern was pri-
marily with accidents and diseases of a strictly
occupational origin while WHO’s interest em-
braced a somewhat wider area of health, then-
activities would inevitably overlap somewhat.
It was decided, therefore, to establish the closest
possible coordination of the activities of the two

252

THE JOURNAL-LANCET

agencies in occupational health. This has been
accomplished through a joint ILO-WHO Com-
mittee on Occupational Health, through close
liaison between the staffs in Geneva, and through
an agreement that experts who serve either ILO
or WHO on special assignments are considered
to be representatives of both. In actual prac-
tice, these arrangements have worked out verv
well. The committee, for example, has held three
meetings, each of which has been highly pro-
ductive.

In their dealings with member nations, it is
quite natural that ILO should establish relation-
ships with ministries of labor and WHO with
ministries of health. At the national level, re-
sponsibility for occupational health may be vest-
ed in health ministries, labor ministries, or in
both. The existence of occupational health pro-
grams in the two international bodies offers easy
and familiar access to assistance regardless of
the administrative pattern in any country.

Up to the present time, the occupational
health work of WHO has been almost entirely
in the fields of education and technical assist-
ance. The educational work involves sending
experts to various countries to give formal in-
struction or to train selected professional per-
sons to handle jobs in occupational health. The
writer has recently completed such a mission in
Egypt. Another important educational activity
of WHO is its fellowship program through which
students are sent from their homeland to other
countries for study and training in occupational
health. Scores of specialists from dozens of
countries have benefited from this program.

A third important educational activity of
WHO is the organization of regional seminars -
dealing with specific occupational health prob-
lems.

The technical assistance program of WHO
provides short-term and long-term consultants
to advise governments on the organization and
administration of occupational health programs

and also provides funds for equipping occupa-
tional health laboratories. Surveys to determine
needs are often a part of the technical assistance
programs.

Space limitations preclude a full description
of WHO activities in occupational health, but
it can be definitely stated that in less than a
decade, WHO has achieved a position of major
international importance in this field.

OTHER INTERNATIONAL ACTIVITIES

While ILO and WHO are the two leading inter-
national organizations concerned with occupa-
tional health, they by no means stand entirely
alone.

A permanent International Commission on
Industrial Medicine has been in existence since
1905. The sole function of this body is to or-
ganize international congresses every three years.
The next will be held in New York in 1960.

The International Society for the Welfare of
Cripples is actively concerned with vocational
rehabilitation and, consequently, must be con-
sidered among international agencies interested
in occupational health.

A number of regional organizations, such as
the Pan American Sanitary Bureau, function in-
ternationally but are not global in extent, and
some of these have been concerned either exclu-
sively or partially with occupational health.

This brief resume should be sufficient to show
that those who are engaged in occupational
health work fully realize the importance of in-
ternational cooperation. The many countries in
which the development of industry has become
a part of national planning now have at their
disposal substantial assistance from WHO and
ILO. The trends in public health which have
evolved in the industrialized nations will un-
doubtedly be repeated elsewhere. This means
that occupational health will grow in importance
and that the international agencies will be called
upon for ever-increasing activity in this field.

JUNE 1958

253

Food and Health

R. C. BURGESS, MB., Ch.B., D.P.H., D.T.M.&H.
Geneva, Switzerland

The words, “food” and “health,” evoke a dif-
ferent reaction in each of ns according to
our own particular interests, knowledge, and ex-
perience. To a public health worker in the inter-
national field, these words bring to mind scenes
varied in detail but usually with one common
feature in the foreground — a village child who
is unhealthy because he has not had enough of
the right kinds of food. Recently, the figure of
the urbanized adult who has had too much to
eat all his life has been added. Our first thought
and main concern, however, is with the under-
or malnourished child and the environment in
which he lives and grows so precariously.

The infant mortality rate has long been con-
sidered an index of the general level of public
health and development in any region. More
recently, it has been recognized that the mor-
tality rate in the group aged 1 to 4 years is per-
haps a more sensitive index of the extent of the
environmental hazards which are the concern of
the public-health worker. In countries where
the infant mortality rates are 5 to 10 times higher
than those of the economically developed coun-
tries, the mortality rates in the 1- to 4-year age
group are 10 to 20 times higher than the corre-
sponding rates in the more wealthy countries.1
The evidence suggests that nutritional factors
may play a large part in the creation of these
high rates in this age group.2 The task becomes
one of scrutinizing the evidence, seeking the
measures which seem likely to lead to a reduc-
tion in the nutritional component of the total
mortality, and assisting governments to devise
the means of putting these measures into opera-
tion.

In parts of the world where children suffer
from lack of food, or malnutrition, the child
usually shares the adult diet. Concessions to
his immaturity are made in the form of omission
rather than the provision of special foods. Fre-
quently, therefore, efforts to improve the health
of the child by changes in the food he consumes
can best be made through improvement in the

r. c. burgess is chief of the Nutrition Section of the
World Health Organization xcitlx offices in Geneva,
Switzerland .

food supply and the eating habits of the total
population.

In his approach to the problem of improving
child health by improving child nutrition, the
international worker has the help of many peo-
ple engaged in different fields of work in many
parts of the world. The most difficult task is to
ensure that the results of this teamwork will be
accepted and used by the most important influ-
ences in the child’s environment — the parents,
the family, and the community of families in
which he lives.

The chief obstacle to a ready acceptance is
the fact that, to parents in the hungry parts of
the world, the words, “food” and “health,” may
have meaning and implications which are not
dreamed of in our philosophy. Though the rela-
tion between food and health has long been rec-
ognized and rules have been laid down in every
society as to what should or should not be eaten
at all times or in certain circumstances, the in-
structions have been mainly in the form of pro-
hibitions for the avoidance of illness rather than
injunctions for the promotion of health. “What-
soever goeth upon the belly, and whatsoever
goeth on all fours, or whatsoever hath more feet
among all creeping things that creep upon the
earth, them ye shall not eat ...” (Lev. 11:42).
The taboos of this type are more widely recog-
nized than the commandments.

The health worker, heir to the scientific tra-
dition, often finds the reasoning behind many
of these ancient rules and prohibitions difficult
to follow, although the actual practice may, on
occasion, be justifiable scientifically. For exam-
ple, in some parts of Peru pregnancy is regarded
as a vulnerable state and certain foods are for-
bidden during this time. A pregnant woman mav
not eat “sleeping food” — food which has been
cooked the night before and left in the pot. To
the Peruvian woman the food is “cold and,
therefore, harmful to her.2 To the bacteriologi-
cally minded, this left-over food is a likelv source
of food poisoning, especially if eaten without re-
heating and, therefore, a potential danger to
anyone who may eat it. In this instance, although
the approach is different, the end result is the
same.

254

THE JOURNAL-LANCET

Many of these ideas seem completely incom-
prehensible, irrelevant, and sometimes positively
harmful. The health worker slowly comes to un-
derstand that “you cannot take a modern con-
cept like nutrition, built on the relation between
food and health, and expect to find its precise
counterpart in the beliefs and practices of a
people living under different cultural influences
from our Western society . . . (and) in order
to examine a people’s attitude to disease you will
have to take the inevitable plunge into their
Weltanschauung — to understand their thoughts
about the nature of the universe, their ideas about
the origin of good and evil, about the motive
springs of human conduct.

In many parts of the world, for example, it
is taken for granted that intestinal worms are
an inevitable part of childhood. In some Asian
countries, the parents do not give the child under
4 or 5 years of age fish or eggs because these
foods “cause” worms. Elsewhere, various rules
exist about avoiding certain foods because they
“disturb” the worms and giving others because
they “draw the worms down into the stomach”
where, presumably, they belong.5 Here, perpet-
uating this obvious and practically universal
menace to child health, are ideas about the na-
ture of a child, about its anatomy and physiolo-
gy, about the properties of certain foods, and
about curative and preventive medicine which
not only perpetuate one menace, but also exacer-
bate another — the world-wide and serious prob-
lem of protein malnutrition in children.

The relationship between food and health has
qualitative as well as quantitative aspects. In
some parts of the world, the health of the pop-
ulation is impaired by the scarcity of all kinds
of foods necessary to provide the requisite calo-
ries and nutrients. In other areas, the quality of
the food is unsuitable for the maintenance of
full health and particularly the health of the vul-
nerable groups — pregnant and lactating women
and young children. In these circumstances,
deficiency diseases — beri beri, pellagra, anemia,
and avitaminosis A — are to be found in varying
degrees of severity, complicated by the intes-
tinal infections and infestations which abound
where standards of living and environmental hy-
giene are low.

A great deal of attention is being given today
to the form of malnutrition which occurs in
young children around the time of weaning
“where diets are habitually poor in protein, while
they are more nearly adequate in calories.”0

Study of the conditions which predispose and
contribute to the occurrence of protein malnutri-
tion or kwashiorkor as it is most frequently

MR. BURGESS

called, shows how far from simple the relation-
ship between food and health can be and how
closely it is interwoven with the whole pattern
of life of the community.

In many countries, for one reason or another,
no milk and no food other than some parts of
the normal adult diet are given to the breast-fed
child to tide him over weaning. All too fre-
quently, this adult diet is largely coarse and
bulky cereal, which the child cannot consume
or digest in sufficient quantity to provide himself
with enough protein for his growing needs.
Moreover, tradition may dictate that the males
or the older members of the family have the first
claim on the scarce protein delicacies in the fam-
ily diet.7 Sometimes eggs are available, but, an
egg, if sold in the market, will provide more than
enough money to buy enough dried fish or cereal
to feed the whole family for that day.8 It is
therefore unlikely that the egg will be given to
the insignificant and useless youngest member.
This is particularly true if it is an unheard-of
idea in the society that special food should be
prepared or bought for a child.

Even if the family can afford to buy or use
eggs for home consumption, the belief that such
things are harmful in one way or another may
deprive the child of this or other sources of pro-
tein, such as meat or fish. Again, the local folk
medicine may rule that diarrhea, which is often
part of the clinical syndrome caused by protein
malnutrition, should be treated by withholding
all food except a thin carbohydrate gruel. This
has disastrous effects for the already protein-
deficient child. '

Other traditional practices also have their
effect on the relationship between the health and
food of the young child. In some parts of Africa,
it is usual for the child to be sent to live with

JUNE 1958

255

a grandmother or other relative for varying pe-
riods of time. This separation from the mother
and other forms of maternal deprivation less dra-
matic, but none the less real to the child, often
coincide with weaning, and it is thought they
may act as a contributing factor in the onset of
kwashiorkor. The anorexia which is such a con-
stant feature of the disease may, in these cases,
be an anorexia of despair caused bv the child’s
feeling of rejection.9

The change from a rural agricultural life to
urban industrial conditions which many people
are undergoing today lias its influence on the
child’s food and health. In the adoption of new
ways of living, the rate of change is uneven and
the “untoward retention of custom” which Bacon
realized coidd be “as turbulent a thing as an in-
novation” may create nutritional havoc in one
of two ways. Where the child in the traditional
rural setting was breast fed for two or three
years, it probably did not matter greatly that
custom forbade that he should be given available
protein in the form of fish or eggs during these
early years. When the child is weaned at six
months or a year because the mother has to work
for a living outside the home or because the
old methods of regulating pregnancies have gone
with the decline of custom1 2 3 4 5 6 7 or the family’s au-
thority,10 the continuance of this ban on a cheap
and available source of protein, such as fish, may
be disastrous to the child’s health. Similarly,
prolonged breast feeding carried out by an iso-
lated, overworked mother in an urban setting,
relying on a meager cash income for her own
and her child’s nourishment, may be equally
damaging to the health of her child.11

The social and psychologic factors which in-
fluence the delicate balance between food and
health are only beginning to be investigated in
countries at varying stages of economic develop-
ment, but it becomes clear from the reports
already available that, although the problem
changes, it remains.

While the breast-feeding mother in the African
village still takes her competence for granted and
is obviously justified in doing so,12,13 “It seems
that the breast feeding mother in modern urban
society often has to accept a heavy load of dis-
comfort and disability and that this is attrib-
utable more to her way of life than to the fact
of breast feeding per se.”14

While half the world suffers from lack of food
or lack of certain kinds of food, the other half
is beginning to be aware that too much food, or
too much of certain kinds of food, can also have
a dangerous effect on health.

The diseases of plenty promise to be just as
closely related to the whole pattern of life in a
highly industrialized society as the diseases of
scarcity are to the habits of living in the remote
tropical or mountain village. What would hap-
pen to the economy of the Western World if, in
the interests of longevity, the rich sauces and
creamy delicacies were to disappear from the
restaurant or domestic dining table, or if, in the
interests of dental health, sweet candies and
sticky cakes were seen no more in the shops?

More and more the public health worker, try-
ing to raise standards of health bv improving
the relationship between food and health, re-
alizes that his task touches all aspects of life and
that he is indeed involved in mankind.

REFERENCES

1. Demographic Year Book 1956. (United Nations).

2. Wills, V. G., and Waterlow, J. C.: The death-rate in the
age-group 1—4 years as an index of malnutrition. J. Trop.
Paed. No. 4, 3:167, 1958.

3. Wellin, E.: Pregnancy, childbirth, and midwifery in the

valley of lea, Peru. WHO Spec. Report MH/ AS/ 160.54
(mimeo.), 1953. Also, Health Information Digest for Hot
Countries, Vol. 3, No. 1, C.C.H.E., London, 1956.

4. Read, M.: Cultural factors in relation to nutritional prob-

lems in the tropics. Proc. 4th Internat. Congresses on Trop-
ical Medicine and Malaria. 2:1196, 1948.

5. Freedman, J. D.: The social factors in the etiology of

kwashiorkor in Guatemala. WHO Spec. Report MH/AS/ 13.57
(mimeo.), 1957. Also, Health Information Digest for Hot
Countries, No. 6, C.C.H.E., London, 1957.

6. WHO Tech. Rep. Ser., No. 72, 1953. Joint FAO/WHO Ex-
pert Committee on Nutrition, p. 5.

7. Manson-Bahr, P.: Fijian kwashiorkor. Docum. Med. geog.

et trop. 4:97, 1952.

8. Freedman, M.: A report on some aspects of food, health

and society in Indonesia. WHO Spec. Report MH /AS/2 19.55
(mimeo.) p. 31, 1955.

9. Dean, R. F. A., and Geber, M.: The psychological changes
accompanying kwashiorkor. I.C.C. Courier, No. 1, 6:3. Also,
Psychological factors in the aetiology of kwashiorkor. WHO
Bulletin, 12: 471, 1956.

10. Opler, M. E., and Radra Dath Singh: Economic, political
and social change in a village of north central India. Human
Org. Vol. 11, No. 2, 1952.

11. Oomen, H. A. P. C.: Food and health in average Djakarta
toddlers. Common, of Min. of Health, Indonesia, Nov. 1954.

12. Matthews, D. S.: The ethnological and medical significance
of breast feeding: with special reference to the Yorubas of
Nigeria. J. Trop. Paed. No. 1, 1:9, 1955.

13. Welbourn, H. F.: Bottle feeding, a problem of modem

civilisation. J. Trop. Paed. No. 4, 3:157, 1958.

14. Hytten, F. E., Yorston, J. C., and Thomson, A. M.: Diffi-
culties associated with breast feeding. Brit. M. J. 1:310. 1958.

256

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Tuberculosis: A Decade in Retrospect
and in Prospect

CARROLL E. PALMER, M.D.

Washington, D. C.

When it became apparent ten years ago
that the long-felt need for an effective in-
ternational health organization would finally be
fulfilled, tuberculosis loomed as one of the major
problems to be faced by the new organization.
At that time, no country could claim that it was
even approaching control of the disease. In
some, the strenuous efforts of a generation had
been largely cancelled by the war, and, in others,
antituberculosis work was still no more than the
dream of a few dedicated people. Of even great-
er consequence, the prospects for effective tuber-
culosis control could hardly be called promising.
In most places where mortality and morbidity
records were sufficient to trace its course, tuber-
culosis was giving way to improved standards
of living and the application of a battery of
laborious and not very specific clinical and pub-
lic health procedures; but progress was pain-
fully slow.

Not that the outlook in 1948 was entirely
gloomy. For one thing, diagnostic procedures
were becoming more precise and more effective.
Cultural technics for the examination of speci-
mens for tubercle bacilli, for example, were be-
ing more generally used. Investigations on the
sensitivity and specificity of chest roentgenogra-
phy had shown that dual readings of chest films
provided the most practical guide between the
Scylla of missed lesions and the Charybdis of
unnecessary recalls for false positives. Indica-
tions for chest surgery were being broadened
with improvement in technics and development
of new procedures. The number of hospital
beds for the care of tuberculosis patients was in-
creasing. And of basic importance for diagnosis
and case finding, especially in the United States,
the tuberculin test was rescued from disrepute
by the demonstration that pulmonary calcifica-
tion, once considered pathognomonic of healed

carroll e. palmer is director of research in the
Tuberculosis Program of the Public Health Service
and, from 1949 to 1955, ivas also director of the
World Health Organization Tuberculosis Research
Office.

tuberculosis, was more often due to histoplas-
mosis than to tuberculosis in many parts of the
country. In addition, three new but still un-
proved technics brightened the horizon: (1)

the application of mass photofluorography to
case finding, (2) the remarkable promise of anti-
biotic therapy, and (3) vaccination with BCG.
However, despite occasional outbursts of opti-
mism, it appeared that victory against tubercu-
losis would be won only by a long process of
attrition spearheaded by finding, isolating, and
treating active cases of the disease.

THE PAST DECADE

Even in retrospect, it seems doubtful that the
advances in tuberculosis control actually wit-
nessed during the last ten years could have been
anticipated in 1948. Most noticeable has been
the decline in tuberculosis mortality, a decline
so tremendous that it would have seemed mirac-
ulous to phthisiologists of former years. More-
over, the decrease in mortality has been observed
throughout the world wherever adequate records
have been kept. In the economically more for-
tunate countries, the period of most rapid de-
cline coincided with the decade just completed.
In others, the rapid fall has been delayed, but,
once started, it appears to be similar in most
countries.

Reported cases of tuberculosis have also de-
clined but much less sharply than deaths. Mor-
bidity rates are greatly influenced by the inten-
sity of case-finding efforts, and they have un-
doubtedly been increased during recent years by
the widespread application of chest photofluor-
ography. It is, therefore, probable that the true
incidence of tuberculosis has been decreasing
more rapidly than reports to official agencies of
newly discovered cases would indicate. On the
other hand, because case fatality has also de-
creased considerably, the incidence of disease
could not have declined as rapidly as mortality.
Thus, although a direct estimate is not possible,
the true incidence of tuberculosis must have de-
clined at a rate intermediate between that of

JUNE 1958

257

reported eases and of tuberculosis deaths. And,
the difference betwen incidence and mortality
is probably great enough to make mortality no
longer very satisfactory as the principal index
of the tuberculosis problem.

More important from the epidemiologic point
of view has been the dramatic decline in the
risk of acquiring new tuberculous infections. A
striking example is afforded in the State of Min-
nesota, where it is not unusual nowadays to find
entire school populations that are tuberculin
negative. A broader view for the United States
as a whole can be drawn from the results of
testing young white Navy recruits with tuber-
culin. In 1950, 9 per cent of them were classi-
fied as tuberculin reactors, whereas seven years
later, only about 6 per cent were reactors. The
implication of such findings, substantiated by
tuberculin testing programs in various parts of
the country, is that new infections with virulent
tubercle bacilli in the white population of the
United States must be approaching the low fig-
ure of 1 per 1,000 persons per year. In other
countries where tuberculosis morbidity and mor-
tality rates have also declined rapidly, the inci-
dence of new infections must be correspondingly
low. Unfortunately, widespread vaccination with
BCG has made it impossible to determine the
risk of infection in some countries at the pres-
ent time and, probably, also for years to come.

Many factors undoubtedly have contributed
to the accelerated decline in tuberculous dis-
ease and infection in recent years. The advent
of the mass chest x-ray survey, made possible by
developments in photofluorography, resulted in
the discovery of many previously unknown cases
of tuberculosis. Although the follow-up, isola-
tion, and treatment of newly discovered cases
have often been less than satisfactory, the chain
of infection must have been broken at innumera-
ble points. Moreover, dramatic demonstration of
the extent of the tuberculosis problem in a com-
munity usually resulted in vast improvements in
facilities for diagnosis and care. As in other pub-
lic health matters, substitution of world-wide in-
terest and attention for apathy and neglect must
have been responsible for many changes that
directly and indirectly reduced both the inci-
dence and prevalence of the disease.

It is now becoming increasingly clear that the
introduction and widespread use of specific anti-
tuberculous therapy were probably the most po-
tent measures contributing to these gains. Fur-
thermore, the effective use of the new therapeu-
tic agents was certainly accelerated by earlv
evaluation of each agent in carefully controlled
clinical trials. Never before in the history of

therapeutics has so much sound knowledge
about the clinical usefulness of any drugs been
gained and applied to medical practice in so
short a time. That this should have been ac-
complished for a chronic disease, with all the
difficulties imposed by chronicity, is an outstand-
ing achievement of clinical research in recent
years. The new drugs have probably also had
a significance far beyond the benefits afforded
to individual patients. Their ability to cause
prompt and prolonged reversal of infectiousness
in all except a small proportion of patients may
well prove to be one of the telling blows against
the tubercle bacillus in its struggle to spread
from one human being to another.

Early in the last decade, in many regions of
the world, primary emphasis in tuberculosis con-
trol was placed on BCG vaccination. To a large
extent, this was because control facilities in many
places were completely inadequate to cope with
the tuberculosis problem, and BCG vaccination
was found to be both administratively and eco-
nomically feasible. The use of BCG was based
primarily on the assumption that tuberculin re-
actors had acquired resistance to tuberculosis
and that most of the future cases would, there-
fore, appear in persons who were yet to be in-
fected. Vaccination, it was felt, substituted a
safe, benign infection for the hazards of a pri-
mary infection with virulent organisms. For
these reasons, millions of persons were vaccinat-
ed, a high proportion of them in the international
mass BCG campaigns in Europe, Asia, and Af-
rica. A few controlled trials of vaccination were
also conducted during this period, although not
in connection with the mass campaigns. While
most of the trials agreed in reporting that vac-
cination confers some resistance against tuber-
culosis, there were pronounced differences in

258

THE JOURNAL-LANCET

estimates of the usefulness of vaccination in di-
minishing the total tuberculosis problem. It
seems unfortunate that scientifically controlled
trials were not made an integral part of the in-
ternational BCG campaigns because, as the mat-
ter now stands, it will probably never be possible
to estimate the effect of the campaigns on tuber-
culosis mortality and morbidity. However, as
the decline in tuberculosis has been so similar in
many countries without any apparent relation
to the amount of vaccination that has been done,
it is becoming increasingly evident that vaccina-
tion can hardly have been a significant factor in
the recent changes in tuberculosis.

The mass campaigns yielded a great deal of
useful information, however. Results of the ex-
tensive prevaccination tuberculin testing, for ex-
ample, were reported in a fairly standardized
way so that meaningful comparisons could be
made of the pattern of tuberculin sensitivity
from country to country. Field research, includ-
ing that coordinated with the mass vaccination
campaigns, showed that not all tuberculin sen-
sitivity is specific for tuberculous infection and
that the prevalence of nonspecific sensitivity
varies widely in different parts of the world.
While nonspecific sensitivity obviously compli-
cates the interpretation of tuberculin reactions,
the test still serves as our most satisfactory
screening procedure when due attention is paid
to the dose of tuberculin and other technical
factors now known to influence the classification
of “positives” and “negatives." Clinical and lab-
oratory studies have also contributed in the last
few years to the problem of nonspecific tubercu-
lin sensitivity bv showing that strains of acid-fast
bacilli isolated from sputum and gastric speci-
mens in some areas frequently are neither typ-
ical virulent tubercle bacilli nor nonpathogenic
saprophvtes but have characteristics intermedi-
ate between the two. The role of “atypical” or-
ganisms both as disease producers and as tuber-
culin sensitizers of human populations is cur-
rently the subject of wide and intensive study.

Students of tuberculosis have long held that
the disease thrives best in populations suffering
from economic deprivation and substandard hv-
gienie conditions. Although it is impossible to
assess the role of these factors in recent changes
in tuberculosis, the fact cannot be denied that
the problem has been less serious and improve-
ment more pronounced in countries with more
favorable socioeconomic circumstances. It is dif-
ficult to escape the conclusion that improvements
in nutrition, housing, and general sanitation have
played a potent and, perhaps, crucial role in
these changes.

Whatever the reasons, tuberculosis in the dec-
ade just ended has finally been deprived of its
rank as a leading cause of death in many coun-
tries. Fewer people are becoming ill with the
disease and the widespread use of effective thera-
peutic agents has diminished still further the
sources of infection. As a consequence, the risk
of acquiring new infections appears to have be-
come so much less in many areas of the world
that the number of infected persons — the seed-
bed of disease — is rapidly diminishing. Viewed
as a world-wide problem, however, the principal
change in tuberculosis in the past decade has
been a widening in the magnitude of the prob-
lem from one country to another. Tuberculosis
mortality, for example, ranged ten years ago
from several hundred to around 30 per 100,000,
and very few countries had rates as low as 30.
Today rates over 100 are still reported from some
countries, but, in others, they are below 10 and,
in a few, are approaching the remarkably low
figure of 5. The new challenge for tuberculosis
control during the next decade is, therefore, to
determine what can and should be done in the
increasing number of countries in which the dis-
ease can no longer be regarded as a major public
health problem.

THE NEXT DECADE

There are, I believe, firm grounds for optimism
about the future of tuberculosis control and
for the prediction that progress throughout the
world during the next decade will far surpass
that made during the last. The investment of
many years of clinical, laboratory, and epidemio-
logic research in tuberculosis is beginning to pay
dividends, as are the highly developed tubercu-
losis control services already in operation. About
the only deterrent to further rapid progress that
I can foresee is that those who influence both
research and service programs might be misled
by the fallacy that because tuberculosis is los-
ing its position as a major public health problem,
it is no longer a serious problem.

In countries in which tuberculosis mortality
and morbidity rates are still high and which also
face difficult problems of nutrition, housing,
sanitation, and so on, changes in the tubercu-
losis picture can be expected to broadly reflect
improvements in the socioeconomic situation.
While progress may be slow in some areas and
relatively rapid in others, the rate of decline of
tuberculosis undoubtedly can be accelerated by
continued application of control measures that
have proved useful in the past. The hope of
rapid changes, however, will probably depend
largelv on the development and application of

JUNE 1958

259

practical methods for using the antituberculosis
drugs. Preliminary results of studies already in
progress indicate that these drugs, particularly
isoniazid, may prove to be highly useful on an
ambulatory basis both for patients with active
infectious tuberculosis and for the large groups
who are likely to become spreaders of the dis-
ease. Only time and the results of carefully exe-
cuted studies can show whether the drugs will
also be useful prophylactically in human popu-
lations, but it would be pessimistic indeed to
doubt the promise of this new method of com-
bating the disease.

In countries where great progress has already
been made, tuberculosis work in the future will
certainly differ from what it has been in the past.
Not the least of the differences will be a change
in objective, from control to eradication. At long
last, it is not only possible but, I believe, obliga-
tory to set the goal at eradication and not at
some intermediate stage connoted bv the term
“control.” To eradicate a serious chronic disease
like tuberculosis is not a simple matter, and no
one would presume to think that it can be ac-
complished in a decade or even in two or three.
But, some of the tools and technics for pursuing
such an objective are now at hand, and others
are in the process of development.

Programs directed at total population groups
are too prodigal of funds and energies for coun-
tries in the eradication phase. More precise tech-
nics must be used to pinpoint the reservoirs of
disease and infection. For example, recent ex-
perience in countries with low tuberculosis rates
indicates that the bulk of the new cases is now
appearing in persons who have been tuberculin
reactors for many years. New disease, in other
words, seems to be mainly of endogenous ori-
gin and is largely concentrated in older people.
Therefore, it becomes almost mandatory to focus
attention on tuberculin reactors, particularly on
those in the older age groups who have x-ray
signs of a potentially active lesion. The least that
can be done for these groups at the present time
is to keep them under close surveillance, with
the expectation that isoniazid or some other anti-
microbial agent will prove to be an effective
prophylactic. Another method of further pin-
pointing sources of infection would be a technic
for differentiating completely healed lesions from
smoldering ones that are likely to erupt eventu-
ally into active disease. Such a test would enor-
mously simplify tuberculosis work — many pa-
tients with inactive disease could be discharged
from follow-up and the few who are risks re-
tained under close supervision. A number of
competent investigators are attacking this prob-

lem with great energy, and it is by no means
fanciful to expect that they will be successful.

Although the numbers of persons eligible for
immunization against tuberculosis are increasing
rapidly, it does not seem to me that vaccination
with BCG or any other vaccine that produces
tuberculin sensitivity has a place in an eradica-
tion program. The principal reason, of course,
is that tuberculin sensitivity produced by vac-
cination interferes with the identification of the
infected persons in the population — those on
whom tuberculosis services and preventive meas-
ures must be focused if the disease is to be
eradicated. The growing sentiment in the Scan-
dinavian countries to curtail the use of BCG
undoubtedly reflects the view that vaccination
has not significantly reduced their tuberculosis
problem and that its continued use would only
complicate the task that remains to be done.
On the other hand, if a vaccine were developed
which produced a highly effective and durable
immunity without producing tuberculin sensi-
tivity, we would have another valuable tool for
advancing the day of eradication. Research on
developing such a vaccine is now being carried
out in a number of laboratories; but it will be
difficult to find a population suitable for a trial
of its effectiveness, since such a population
should have a high tuberculosis rate among tu-
berculin nonreactors as well as adequate diag-
nostic and reporting facilities.

In conclusion, it seems to me that, barring a
catastrophe, of course, the momentum created
by successful research and the highly developed
tuberculosis services already in operation will
continue during the next decade to produce fur-
ther significant progress, and that progress will
surely be accelerated by development and ap-
plication of new methods and technics. But
even if, for unforeseen reasons, the anticipated
new methods should fail to materialize, the per-
centage decreases in indices of tuberculosis can
be expected to continue their present trend. Al-
though reductions in mortality, morbidity, and
infection rates may appear most dramatic in
areas in which the present rates are still high,
of fundamental importance to tuberculosis work-
ers throughout the world will be the smaller re-
ductions in low prevalence areas because such
reductions will reflect the development of suc-
cessful methods for pinpointing and eradicating
the last remaining sources of infection. As eradi-
cation becomes the goal of an increasing number
of countries during the next decade, it seems to
me not at all unlikely from present indications
that bv 1968 tuberculosis workers in manv coun-
tries will be in actual sight of their goal.

260

THE JOURNAL-LANCET

Voluntary Agencies in International Health

JAMES E. PERKINS, M.D.

New York City

The United Nations and its specialized agen-
cies, such as the World Health Organiza-
tion, the United Nations International Children’s
Fund (UNICEF), and other official govern-
mental international bodies concerned directly
or indirectly with health problems, have stressed
repeatedly the importance of the nongovern-
mental, or voluntary, agencies which are also
concerned with health problems. For example,
from the time the Tuberculosis Division of the
World Health Organization was created ten
years ago, it has stressed the importance of liai-
son with and the strengthening of the Interna-
tional Union Against Tuberculosis, which is a
federation of voluntary national tuberculosis as-
sociations, in order to establish or improve na-
tional tuberculosis associations in various coun-
tries as a means of gaining public understanding
and support for governmental tuberculosis con-
trol programs recommended by WHO.

In the UN pamphlet The United Nations and
the Non-Governmental Organization, the manner
in which people have organized themselves into
voluntary organizations is commented upon as
follows :

Enlightened persons who had common interests, be-
liefs, or ideals often organized themselves into groups
in order to be in a better position to defend their inter-
ests and the principles in which they believed. A great
many principles which now are generally considered to
be right were thus first promoted by voluntary organiza-
tions.

During the last thirty years or more, a world network
of international, voluntary, nongovernmental organiza-
tions has developed. These organizations have various
major interests, such as peace, religion, politics, the arts,
science, social work, education, agriculture, economics,
health, and humanitarian and professional interests. All
these groups of men and women represent public opin-
ion in a substantial measure and contribute, both na-
tionally and internationally, to the formation of this
opinion in certain fields.

Provision is made bv the United Nations and
its specialized agencies for recognizing volun-

james e. perkins, managing director of the National
Tuberculosis Association, is the official representa-
tive of the International Union Against Tuberculosis
to the 1958 World Health Assembly and to the
United Nations International Childrens Fund. He
is also president of the National Citizens Committee
for the World Health Organization.

tary international organizations which meet cer-
tain criteria. Such a voluntary organization
when officially approved is said to have “con-
sultative status.’ Hundreds of organizations in
different fields have been accorded this status,
which has proved mutually helpful. The or-
ganizations in official consultative status to
WHO have the privilege of nonvoting partici-
pation in the sessions of WHO’s Executive Board
and Assembly. Thus, they have the privilege of
learning first hand of the development of plans
of programs in various areas of public health by
WHO, its regional units, and the member coun-
tries. They have the privilege of suggesting im-
provements in programs related to their special
interests. Conversely, most of these organiza-
tions request that official observers from the
WHO secretariat interested in their specific
fields attend the business and scientific sessions
of their own international voluntary organiza-
tions, which further helps to improve the pro-
grams of both organizations, avoids unneces-
sary duplication, and helps eliminate any gaps
in the program which are not being met by
either the official or the voluntary group.

Most of the voluntary health organizations of
the United States have their international coun-
terparts which they support both financially and
with personal participation. I have already men-
tioned the International Union Against Tubercu-
losis, but there are comparable international
bodies in the fields of venereal disease, poliomy-
elitis, heart disease, cancer, mental health, the
blind, the deaf, the crippled, and other areas.
There are also international voluntary profes-
sional groups, such as the World Medical Asso-
ciation and the International Council of Nurses.
There are voluntary international organizations
in more general fields, such as the League of
Red Cross Societies, the International Confer-
ence on Social Work, the International Union for
Child Welfare, and the International Union for
Health Education of the Public. All of these
organizations are assisting in the improvement
of the health of people throughout the world.

In addition to these international voluntary
organizations, there are national voluntary or-
ganizations specifically interested in official and

JUNE 1958

261

nongovernmental international agencies. Thus,
there is the National Citizens Committee for
WHO here in the United States, and 10 other
countries have comparable citizens’ committees
for WHO. There is the United States Committee
of the World Medical Association and compara-
ble committees in many other countries. There
are national committees for UNICEF in the
United States and Canada and in 17 countries in
Europe. UNESCO (United Nations Educational,
Scientific and Cultural Organization) has 70 odd
national commissions, which in some instances,
are semigovernmental in character. United Na-
tions Food and Agriculture Organization, the
program of which is very important to world
health, has 53 national committees.

Norman Cousins has said: “No community
neighborhood is smaller than the world neigh-
borhood today in the sense that every man’s
welfare and destiny are interlocked with every-
one else’s.” The national voluntary health agen-
cies link these two neighborhoods together with
their intimate contact on the one hand with ev-
erv hamlet in the country and their participation
on the other hand in the affairs of their respec-
tive international organizations.

Bertram Pickard, of Great Britain, has spoken
of “the Greater United Nations” by which he
means governmental and nongovernmental inter-
national organizations. He states:

At a time when governments are assuming increas-
ing responsibility for the welfare of their peoples, the
role of voluntary organizations necessarily shifts in em-
phasis. The era of soup kitchens, orphanages, and pri-
vate charities is fading. Today the nongovernmental or-
ganizations have another primary objective — to be the
conscience of the state and to monitor its activities in the
name of the people.

In the mid-twentieth century, the “Greater United
Nations” is that combination of intergovernmental and
nongovernmental cooperation that strives to assure, in
connection with each and every issue of international
cooperation, that in no country shall national public
opinion lag behind the government, while in every
country the actions of the government shall be consonant
with the best wishes of the people.

. . . Like the United Nations, the Greater United Na-
tions is not in New York, Geneva, or the hundred and
one places where international offices are established. It
is everywhere, not least in the minds and hearts of
“We the People,” the mandatories alike of governments
and organizations.

. . . One of the greatest opportunities of the non-
governmental organizations is to take the initiative with
ideas and projects which governments are not vet ready
to make their own. Here is one advantage the NGOs
have over governments. The forward movement may not
always come from nongovernmental sources, as we have
seen. But, in matters of human relations, where pity and
generosity must find full place lest the impersonality of
bureaucracy and wheels of great machinery crush the
human spirit, and bodies too, NGOs are better placed
than governments to take account of the human factor.

At a meeting of the Economic and Social
Council of the United Nations in October 1957,
it was stressed that the positive role of voluntary
organizations must be emphasized. The dogma
that a people’s efforts were doomed to failure if
they were not supported by the State was un-
tenable. On the contrary, a society was really
organizations of their own choice and direction,
democratic only if its citizens themselves, through
helped to mold the domestic and foreign policies
of their country.

In the foreword to James Hemming’s Mankind
Against the Killer, Dr. Brock Chisholm, the first
director-general of WHO, stressed the fact that
microbes ignore both the national frontiers and
social barriers and that the health of each of us
is, therefore, dependent upon the health of all.
He emphasized the fact that no agency that
works across many frontiers can succeed without
full public support based on knowledge and un-
derstanding of its work.

The nongovernmental organizations are in the
best position to see that there is knowledge and
understanding on the part of local citizens which
will ensure full support of the work of the offi-
cial agencies which are attempting to lessen the
ravages of disease and promote optimum health.

All of this may seem a bit nebulous and im-
practical, so let me conclude by clarifying the
discussion somewhat by indicating some of the
aspects of the program of the International Un-
ion Against Tuberculosis with which I am more
familiar than with the programs of some of the
other international voluntary health agencies.
Although still a very small organization and op-
erating on a very small budget, the International
Union Against Tuberculosis has progressively
grown in scope and influence, particularly in
the last ten years, until it is a definite world-

262

THE JOURNAL-LANCET

wide force in the promotion of the better con-
trol of tuberculosis. It is accomplishing its ob-
jectives by conducting international conferences
every two or three years in widely different loca-
tions — Rio de Janeiro, Madrid, and New Delhi
have been the last three sites — for the exchange
of the latest information on treatment and pre-
vention of tuberculosis. These conferences are
not confined merely to drugs and surgery but to
administrative public health problems, better
methods of health education, improvement of
rehabilitation services, and other areas of im-
portance in the broad program of tuberculosis
control. It has established scientific committees
in specialized aspects of the tuberculosis field,
composed of top experts from countries through-
out the world who bring to these committees
the most advanced knowledge and ideas in their
particular fields. These committees gather and
analyze data on important problems from coun-
tries throughout the world, and, on the basis of
these analyses, formulate authoritative state-
ments of assistance to tuberculosis workers ev-
erywhere. It has appointed regional committees
in Latin America, the Middle East, and Asia to

promote the establishment of national tubercu-
losis associations and to improve the functions
of those associations already in existence. It
conducts special conferences in specialized as-
pects of tuberculosis control, such as on BCG
vaccine and in the field of mass miniature x-
rays. It designates a special observer to attend
meetings of the Executive Board and Assemblv
of WHO and, conversely, invites the director of
the tuberculosis program of WHO to attend
meetings of its own executive committee and
council. It enjoys official consultative status with
WHO. It also maintains official liaison with the
United Nations Children’s Fund, one of the chief
programs of which has been the control of tu-
berculosis among children throughout the world.

Thus, you see these programs of voluntary in-
ternational organizations are not indefinite and
nebulous concepts but practical, worthwhile ef-
forts which slowly, perhaps, but surely exert a
favorable influence in accelerating the objective
of ridding man of disease and helping him attain
the maximum physical, mental, and social well-
being which the WHO charter has laid down as
the right of everv human being.

There are now 1,236,000 physicians serving the world’s 2,700,000,000 in-
habitants, and the 638 medical schools operating in 85 countries graduate
annually about 67,000 physicians. Fourteen countries are fortunate enough
to have 1 doctor to serve everv 1,000 or fewer persons. However, in 22 other
countries, there is onlv 1 doctor for 20,000 or more inhabitants. Between these
two extremes, the rest of the world shows great variations. Usually, there is
a shortage in rural areas, while cities are apt to have an overabundance of
medical practitioners. While 9 countries have 1 medical school for less than

1.000. 000 people, 13 countries have only 1 such school for 9,000,000 to

17.000. 000 people.

JUNE 1958

263

The Contribution of the Hospital to the
Improvement of Health

EDWIN L. CROSBY, M.D.

Chicago, Illinois

All of us in the health field are aware of the
changes the past has brought to the role
the hospital plays in the improvement of health
throughout the world. Representing man’s de-
votion to the welfare of all mankind, the mod-
ern hospital is one of the outstanding construc-
tive achievements of civilization.

Feudal hospitals, built and staffed by religious
orders, had a twofold objective — salvation of
the soul and care of the body. The hospital was
a simple institution with surgical facilities as
crude as the art of surgery itself. Equipment for
diagnosis and therapy was unknown, and care
of the sick was primarilv custodial. Early hos-
pitals in the United States were pesthouses or
quarantine stations for persons with contagious
diseases, almshouses for the indigent and insane,
or emptv buildings taken over to shelter the
homeless sick for emergency and terminal care.
During the greater part of the nineteenth cen-
tury, most people viewed the hospital simply as
a place to die.

The late nineteenth and early twentieth cen-
turies constituted a period of social and eco-
nomic reform, much of it in the wake of ad-
vances in medical science. Between 1850 and
1900, great advances were made in biology, cell-
ular pathology, bacteriology, clinical microscopy,
and physiology. In the United States, the Pure
Food and Drug Act was passed; the National
Association for Mental Health was established;
sanitary engineering received increased atten-
tion; and new public health laws were enacted.

In 1910, the Flexner Report set fundamental
standards for medical schools, stressing the need
for full-time faculties in the basic sciences and
clinical training in hospitals. The rise in medical
standards brought demands for better hospitals,
personnel, and equipment. As standards ad-
vanced and hospital mortality rates dropped,
there was a change in attitude of the public
toward the hospital. It was now pictured as a
place in which the individual who was ill had a

edwin l. crosby is director of the American Hos-
pital Association , Chicago.

better chance for recovery and relief from pain.
Its function had shifted from that of terminal
care for the poor to that of a complex organiza-
tion designed to bring the greatest potential of
medicine to all.

There is presently underway a revolution in
hospital care. A variety of developments, con-
sisting in part of the use of new and complicated
equipment, different treatment technics, and new
categories of highly trained, specialized person-
nel, have changed the picture of hospital care
even in the past two generations. These years
were notable for the evolution of the science of
roentgenology, the isolation of insulin for dia-
betes, the use of liver in pernicious anemia,
elimination of many of the infectious diseases,
the inception of cardiac catheterization and heart
surgery, and the discovery of sulfa drugs and the
antibiotics. New anesthetics have made hereto-
fore impossible surgical procedures feasible; the
utilization of radioactive isotopes points to the
probability of conquering illnesses previouslv
thought incurable. Many of these discoveries
were made in hospitals or were perfected by
hospital research to the point at which they are
used in saving human life.

Through the modern hospital, doctors have
been able to improve medical care and to make
it available to more people. There is no magic
in modern-day medicine. When it is good, it is
good because it consists of tested methods which
were arrived at through research and experimen-
tation. It is largely through the hospital that the
medical profession integrates into its knowledge
and practices the findings of other sciences.

For a long time, the hospital stood alone as
an island of curative medicine. Within its realm,
it did, in many instances, a superb job. It has
ceased, however, to be an island by itself and
has become a part of the mainland of medical
care. Increasingly, it is recognized as the center
of community health; its future role will empha-
size prevention and rehabilitation as well as
diagnosis and treatment. As early as 1936, the
Committee on Public Health Relations of the
American Hospital Association went on record

264

THE JOURNAL-LANCET

as saying that the gradual disappearance of the
line of demarcation between the prevention and
the treatment of disease was one of the new
concepts to be emphasized in an adequate com-
munity health program.

The hospital has felt the impact of dramatic
economic and social developments, one aspect
of which is the increasing appreciation of the
value of good health. New ideas of the respon-
sibility of employers, of unions, and of govern-
ment at all levels for the maintenance of phys-
ical well-being have thrown the hospital into
focus as a point from which health care and
information can be disseminated. More than
twenty-five years ago, hospitals realized that new
ways must be devised to help people budget in
advance for their hospital care. The voluntary,
nonprofit Blue Cross Plans were the answer.
Today there are more than 55 million Blue Cross
subscribers. The plans make direct payments to
the hospitals for the care provided their mem-
bers, with emphasis on the services the patient
needs rather than on the dollars paid. An addi-
tional 65 million individuals are insured through
commercial hospitalization insurance programs.

As a community health center, the hospital
assists the health department in birth and death
registrations, the detection and reporting of com-
municable disease, and the treatment of poliomy-
elitis and tuberculosis patients in a ceaseless
fight against infection. In rural areas in partic-
ular, the health department may use the hospi-
tal’s clinical and laboratory facilities. Many hos-
pitals are inaugurating or improving communitv
educational plans in maternal and child welfare,
sex education, nutrition, mental hygiene, and
early perception of serious illnesses. The closest
cooperation between the hospital and health de-
partment is found in outpatient work.

Hospital operation has changed rapidly with-
out planned development based on research.
However, recent Public Health Service grants
have made possible research on many subjects
including hospital licensure, the future need for
facilities, institutional design and construction,
and many other vital topics.

The program of hospital accreditation, with
surveys of hospitals made onlv after request of
the hospitals themselves, helps to maintain high
standards of patient care. The stamp of approval
conferred by the Joint Commission on Accredi-
tation of Hospitals — a body sponsored by the
American College of Physicians, the American
College of Surgeons, the American Hospital As-
sociation, the American Medical Association, and
the Canadian Medical Association — tells the

community that the institution has been in-
spected and is well run, well organized, well
equipped, and well staffed.

These are a few of the ways the hospital con-
tributes to the betterment of health. For the
future, there are four ways of extending health
services into the community through which even
better care can be afforded to all:

1. There is a need for better-planned coopera-
tion between large and small hospitals in order
that difficult cases can be referred to centers
with specialized facilities and so the specialists
from central hospitals can regularly visit smaller
institutions. There should be a carefully devel-
oped plan in each community to establish co-
operation among health and welfare agencies
and ether institutions offering related services.

2. New rehabilitation programs should be pro-
vided in view of the knowledge that rehabilita-
tion is a vital part of the dynamic therapeutic
picture. The patients of several hospitals in a
given area might well be served by a centrally
situated rehabilitation center.

3. The illnesses that beset the aging, a group
growing in numbers, present another challenge
to hospitals. Much of middle- and old-age sick-
ness is chronic in nature, necessitating hospitali-
zation of relatively short duration. Arrangements
will have to be made for continued home care
and for an adaptation of the full range of serv-
ices now available only to the hospital inpatient.

4. Another area of expanding hospital service
is found in outpatient care. The idea of ambu-
latory service for the community is gradually
being accepted. In the interest of good commu-
unity health, it seems probable that more hos-
pital prepayment plans will offer coverage for
outpatients and for diagnostic technics.

JUNE 1958

265

Heart Disease — A World Health Problem

C. J. VAN SLYKE, M.D.
Bethesda, Maryland

In recent years, heart disease lias been ap-
pearing as the cause of death on the death
certificate with greater and greater frequency.
At the same time, deaths caused by tuberculosis
and the contagious diseases are diminishing.

Heart disease today knows no international
boundaries. However, for all its magnitude and
scope, it suffers from a lack of world-wide inves-
tigation. This is in sharp contrast to the infec-
tious diseases which have inflicted the world for
so many years. Quite logically, these diseases
have been studied and are being controlled first,
while heart disease and cancer have not. Within
a generation or so, depending upon how rapidly
the infectious diseases are controlled, heart dis-
ease and cancer very likely may head the list of
world-health enemies. When one considers for
a moment the statistics available from just 7
nations, the emergence of heart disease as a
world problem is evident. In 1954, the United
States, Finland, Australia, the United Kingdom,
New Zealand, Canada, and Switzerland reported
deaths due to arteriosclerotic and degenerative
heart diseases at a rate in excess of 600 per
100,000 population.1

International cooperation and world-wide
study have become a matter of routine in dealing
with widespread diseases like malaria, leprosy,
and tuberculosis. The pioneer work of the Rocke-
feller Foundation and the World Health Organi-
zation, transcending international boundaries,
has broken the ground and shown the way. Such
footsteps might well be followed in gathering
further information about diseases such as rheu-
matic fever, hypertension, and arteriosclerosis.
Also, pioneering efforts might well be made to
collect information on the incidence and severity
of heart disease under a complexity of conditions
and in every corner of the earth. For centuries,
nature has been conducting gigantic experiments
involving differences of climate, altitude, type of

c. j. van slyke is associate director of the Public
Health Service’s National Institutes of Health, Be-
thesda, Mart/land. A graduate of the University of
Minnesota, he teas honored with an Outstanding
Achievement Award from the University in 1952
and was a 1957 recipient of the Lasker Atcard for
public health administration.

work, and differences of diet on people of dif-
ferent races. This canvas is spread before our
eyes to record and to analyze.

Laboratory animal experimentation has yield-
ed significant clues which have led to important
discoveries, yet, if we place our sole reliance on
such experiments, we are in effect neglecting a
valuable source of information about cardiovas-
cular diseases. Animal experiments, even under
the most exacting conditions, cannot be com-
pletely applied to man. Human reasoning has
enabled man, for example, to institute major
changes in his environment. This has served to
remove various possibilities of paralleling animal
adaptations to those of human beings.

Surveys both here and abroad are slowly ac-
cumulating information, but this is a slow proc-
ess. Also, lack of comparability of data often
makes meaningful interpretations impossible. We
need well-organized studies that can collect clin-
ical and pathologic information on heart dis-
ease over several years, not just from hospital
clinics and private practice but from entire com-
munities. By these means we can learn more
about host and environmental factors related
to hypertension, rheumatic fever, and coronary
heart disease. Challenge and hope lie in the sim-
ple fact that the morbidity and mortality from
heart disease differ with populations and coun-
tries. What we learn about the Bantu, the Japa-
nese, and the Italians becomes a challenge to
us in the United States and in Northern Europe.

Present knowledge of heart disease incidence
and mortality in different populations and pop-
ulation segments is rudimentary. We look for
some of the answers in vital statistics, but much
of the desired data is missing or incomplete and
what is available must be carefully analyzed.
Wartime experience of the Scandinavian coun-
tries has demonstrated cpiite clearly that the
problems of arteriosclerotic heart disease in a
given population can change in as short a time
as a year or two.

International action has begun on world pub-
lic health problems involving heart disease.
Members of groups such as the International So-
ciety of Cardiology, the International Congress
of Internal Medicine, and the World Health Or-

266

THE JOURNAL-LANCET

ganization have been attempting to meet the
universal heart disease problem since World
War II.

The third Regional World Health Organiza-
tion Conference of Europe, meeting in Copen-
hagen in 1953, recognized cardiovascular disease
as a public health problem of international con-
cern and recommended that a study group be
organized to stimulate further action in this
field. In 1954, the Food and Agriculture Or-
ganization and the WHO Expert Committee on
Nutrition proposed that WHO give considera-
tion to the possible relationship between the
character and the amount of habitual diet and
the development of atherosclerosis.

As a result, a special meeting of a Study Group
on Atherosclerosis and Ischemic Heart Disease
was held in Geneva in November 1955. This in-
ternational group (knowledgeable in cardiology,
pathology, physiology, biochemistry, epidemiol-
ogy, nutrition, biometrics, and public health) con-
sidered many aspects of the over-all problem of
atherosclerosis and reported its recommenda-
tions to WHO. The report has a valuable docu-
mentation of the needs and recommendations
for further research and international coopera-
tion.2

Interest in such cooperative efforts has grown,
and tangible results are beginning to be evident.
In the fall of 1957, an international group of
pathologists met in Washington, D. C. with the
support of a National Heart Institute grant and
drew up and adopted a classification of athero-
sclerotic lesions found at autopsy. This system
of classification will be recommended to WHO
for adoption throughout the world. Such uni-
form classification of autopsy findings would be
especially valuable in comparative epidemiologic
studies of atherosclerosis in different countries.
Such comparative studies are already under way
in some South American countries, and there is
indication that they will expand to other areas.

A decrease in the mortality of rheumatic fever
and rheumatic heart disease in certain countries
has occurred during the last few decades. Nev-
ertheless, they continue as an important cause
of morbidity and mortality among children and
young adults in many parts of the world. Avail-
able statistics underestimate the total morbidity
attributable to rheumatic fever and rheumatic
heart disease, since many patients survive the
initial attack of rheumatic fever and develop
trouble from their valvular disease only in later
years. Evidence of the effectiveness of rheu-
matic fever prevention measures has accumulat-
ed to a point where preventive action on a world
basis is both justified and needed.

In addition to the needs for standardization of
both clinical and pathologic criteria and termi-
nology in respect to atherosclerosis, coronary
heart disease, and related conditions and for fur-
ther agreement with respect to methods of exam-
ining, assessing, and reporting on necropsies with
particular regard to coronary arterv and myocar-
dial lesions, uniform criteria should be estab-
lished for the clinical diagnosis and classification
of cardiovascular diseases in a manner which
will be applicable to epidemiologic and other
statistical studies. Also, attempts should be in-
stituted to achieve comparability in pertinent
laboratory estimations of serum cholesterol and
cholesterol-bearing lipoproteins.

There is a scarcity of available data that are
of special interest from many populations. Exist-
ing data usually are inadequate in several re-
spects. For example, dietary information is gen-
erally collected on a family basis, even though
the results are expressed in terms of per con-
sumption unit. It is essential to have data on
personal food habits so that the diets of persons
in different age groups, especially of men and
women in middle age and beyond, can be ascer-
tained. The nature and source of specific food
constituents in the diet present another area
where information is sorely needed, though sig-
nificant work has been begun and is continuing
in this area.

FAO is making a valuable contribution toward
meeting some of these needs by assembling and
providing appropriate data on food consumption
following the recommendations of the Joint
FAO/WHO Expert Committee on Nutrition.
FAO should be encouraged to continue the stim-
ulation of well-planned dietary surveys to obtain
as soon as possible this needed information on
diet for different parts of the world.

JUNE 1958

267

The Joint FAO/WHO Expert Committee on
Nutrition already has drawn attention to the fact
that malnutrition from excessive consumption of
food with resulting obesity is becoming an im-
portant world health problem. Since coronary
heart disease may be in some way associated
with the excessive consumption of certain foods
or nutrients, it is desirable for international agen-
cies, as well as for the national organizations
concerned with these problems, to explore the
question of maximum limits for the requirements
of calories and nutrients, including fats.

Possible preventive methods must be justified.
Great hope for revealing new factors concerned
with prevention lies in the field of epidemiology.
Studies already in progress are evidence of the
potentialities of the epidemiologic approach to
these problems.

The needs shown in epidemiology are but a
sample of the whole critical problem which must
be met if we are to focus on heart disease as a
world health problem to any meaningful degree.

A genuine threat to the future of all medical
research has arisen largely because of the inade-
quate attention to the training of manpower for
the years ahead. Support of medical research
cannot be divorced from research manpower
and from the strength of the institutions which
train research manpower. It is manifest that
concentration upon support of current research —
necessary and valuable as it is — has not been
accompanied by enough attention to all of the
factors entering into the production and main-
tenance of a larger international pool of highlv
qualified medical research scientists.

In the field of coronary heart disease in par-
ticular and of the metabolic and noninfectious
diseases in general, there is a shortage of ex-
perienced researchers who are familiar with
social and clinical problems as well as epidemio-
logic methods. One clear and positive step can
be taken to ameliorate this situation. The fur-
therance of postgraduate training in appropri-
ate centers should be encouraged. This can be
achieved by ( 1 ) drawing attention to the im-
portance of encouraging and promoting work
in this field; (2) identifying host and environ-
mental situations that offer special opportunities
for study, including populations undergoing
rapid social change and populations with ap-
parently great contrasts in experience with heart
disease; and (3) making available qualified con-
sultants to assist in the design of surveys and in
the analysis of the residts.

Steps to resolve these problems are among the
most urgently needed in the whole field of med-
ical research in order to give the world an ade-

quately balanced total medical research pro-
gram. Well-trained scientists are the most im-
portant single factor in determining whether or
not progress is made over the years to come in
the continuing war on heart disease.

Money and facilities are urgently needed. A
way must be found to provide them. In many
universities, medical schools, and other related
research institutions, the absence of adequate
laboratory space is the most important single
cause restricting the volume and kind of med-
ical research that must be undertaken. The finan-
cial status of medical schools is such that very
few can undertake construction of buildings
from their own funds or from private gifts.

Progress in the conquest of disease depends to
a very large extent on an uninhibited flow of
communications between the physician and the
investigator. Vast problems exist in opening and
keeping open these channels of communication.

A more extensive exchange of information de-
mands our attention. There needs to be a more
widespread exchange of experience among
workers interested in the problem of heart dis-
ease from different parts of the world. Attend-
ance at meetings, congresses, symposia, and con-
ferences is one of the most effective means of
communication among scientists. Most private
and governmental research-supporting organiza-
tions recognize their great value, and grants
in support of research usually provide small
amounts of money for travel assistance. If there
is to be hope for any real cross-fertilization of
the minds and for significant improvement of
public health, it is important that the men work-
ing in this area have funds sufficient to attend
these scientific meetings. This is one of the most
important ways in which they can bring knowl-
edge back to their own countries and have it
shared for national benefit.

Research workers in foreign institutions re-
ceive National Heart Institute support to carry
out investigations of problems unique to their
countries yet extremely valuable to heart re-
search as a whole. The investigation of ather-
osclerosis among the Bantu in South Africa is
but one example.

Scientists from the United States, supported
by National Heart Institute fellowships, work
in many of the research centers of other coun-
tries learning and exchanging their knowledge
and skills. In a similar pattern, scientists from
other countries are coming to America to share
their experiences with us and to gain knowledge
which will broaden the medical talents of their
homelands. Beneficial expansion of such valu-
able programs should be encouraged in many

268

THE JOURNAL-LANCET

fields since important advances in medical re-
search are being made in many countries which
will be of benefit to all.

The results of experiments already being done
in a few countries that have health programs
aimed at the prevention, early detection, and
control of heart disease are important to all of
us. The outcome of these studies and additional
research may soon suggest more effective pre-
ventive programs to health authorities.

Leadership should be provided to create a
mechanism of pooled support for training skilled
researchers. Existing research facilities recpiire

improvement. Additional facilities should be
constructed. The exchange of medical informa-
tion should be extended and broadened.

WHO might suitably assist in planning and co-
ordinating the development of certain interna-
tional research efforts which it would be unique-
ly qualified to foster. Group support for a pro-
gram such as this would return ultimately to
each member nation a positive dividend in the
form of improved national health. This is true
just as surely as the present interchange of sci-
entists, limited though it is, mutually increases
national research skills.

REFERENCES

1. Annual Epidemiological and Vital Statistics. WHO, Geneva, 2. Study Group on Atherosclerosis and Ischemic Heart Disease.
1957. WHO Technical Report Series No. 117, Geneva, 1957.

The decline in mortality is the most significant demographic event of the
last decade. In the world as a whole, death rates for 1950 to 1954 were lower
than those for 1945 to 1949, and countries with the highest death rates in the
earlier period experienced the greatest reduction.

The decline mav be attributed in the main to advances in environmental
sanitation and disease control, and it is reflected in increased life expectancy

almost everywhere. In the more developed countries, a newborn girl can be
expected to live four to five years longer than ten years ago and a newborn
boy three to four years longer. In some of the countries undergoing rapid
development, life expectancy at birth has increased to eleven years for girls
and ten years for boys.

With a decreasing rate of death and an almost unchanged birth rate, the
population of the world — now about 2,700,000,000 — is growing rapidly. Ev-
ery hour almost 5,000 persons are bom, or 120,000 per day, or 43,000,000 per
year — an increase calculated to double the world’s population by the end of
the century.

JUNE 1958

269

Progress in the Control of Cancer

HAROLD S. DIEHL, M.D.

New York City

Deaths and death rates from cancer have
been increasing so steadily over the past
half century that one might well question the
justification of an article entitled “Progress in
the Control of Cancer.”

From the position of eighth among the causes
of death in this country in 1900, cancer has now
risen to the second position. This increase has
been due mainly to factors such as the control
of communicable diseases and the increasing
age of the population. Whatever the causes,
the fact is that in 1957 a quarter of a million
persons in the United States died from cancer.

Fortunately, this is not the complete story.
An analysis of cancer deaths shows that in re-
cent years, the death rates for certain age groups
and sites of origin have not increased; in some
instances, they have actually decreased. For
example, over the past twenty years cancer
death rates among women 25 through 84 have
decreased. Overbalancing these decreases, how-
ever, have been the substantial increases among
men aged 45 and over (figure 1).

When analyzed according to sites of origin,
cancer death rates show varying trends (fig-
ure 2). Lung cancer has shown a steady and
impressive increase. Some of this may be at-
tributed to better diagnosis and reporting, but
it is believed that a large part represents a real
increase in incidence. While increases have been
recorded also for leukemias and cancers of the
pancreas and ovary, notable decreases have been
noted for cancers of the uterus, skin, and buccal
cavity. Incidence of cancers of the liver and
stomach has declined. In the case of the liver,
the increasing recognition of secondary can-
cers of the liver and proper assignment of these
cases to the primary site of cancer would account
for the decline. For stomach cancer, the decline

harold s. diehl, former dean of the University of
Minnesota Medical School, is senior vice president
for Research and Medical Affairs and deputy execu-
tive vice president of the American Cancer Society,
Inc. He is a member of the World Health Organiza-
tion Expert Advisory Panel on Organization and
Medical Care and was a member of the United
States delegation to the World Health Assembly in
1954 and 1955.

is perhaps due partly to more precise specifica-
tion of internal cancers. This decline may, how-
ever, indicate a real decrease in the incidence
of this form of cancer.

Over-all, these data point to the areas toward
which our greatest future efforts should be di-
rected. They show that, although the problem is
not simple, progress can and is being made.

Another measure of accomplishment in deal-
ing with cancer is the proportion of patients
whose lives can be saved or substantially pro-
longed by appropriate treatment. Here again
we find some basis for gratification and encour-
agement. Twenty years ago, the American Can-
cer Society estimated that 1 out of 7 patients
diagnosed as having cancer was saved. Ten
years ago, the figure rose to 1 out of 4, and, now,
the statistics are 1 out of 3.

Such achievements to date and our hopes for
the future rest primarily upon research to pro-
vide more effective measures of prevention, early
diagnosis, and treatment, together with programs
designed to obtain the widest possible utilization
of measures of demonstrated value.

CANCER RESEARCH

Major research efforts in the field of cancer date
back little more than a decade. Yet, during this
period, substantial progress has been made not
only in advancing scientific knowledge regard-
ing cancer but also in the training of research
personnel and the provision of facilities to en-
able them to work effectively.

Among the definitive research achievements
directly applicable to cancer control are:

1. The development of exfoliative cytologv
as an aid in the early detection of cancer, par-
ticularly of the female genital tract.

2. The utilization of radioactive chemicals for
the diagnosis and treatment of cancer.

3. Improvements in surgical and supportive
surgical technics and services which make pos-
sible more extensive and prolonged operative
procedures.

4. The employment of various chemicals and
certain endoerines, such as estrogens, androgens,
ACTII, and cortisone, for treatment. The effects
of most of these are temporary and palliative,

270

THE JOURNAL-LANCET

but a few result in prolonged and possibly per-
manent improvement.

5. Substantial additions to scientific knowl-
edge regarding basic biologic and chemical
processes that are related to the cancer process.

Of greater importance than the research ac-
complishments to date are the potentialities
which have been developed for productive re-
search in the future. In 1944, the total amount
of money expended throughout the country for
research on cancer was a mere $500,000. By
1957, this total increased to substantially more
than $50,000,000. These funds make it possible
for thousands of investigators with worthy can-
cer research projects to be supported. Further-
more, the availability of adequate support, some
of which is on a long-term basis, encourages sci-
entists to devote themselves to work on the can-
cer problem.

To increase further research potential, both
the American Cancer Society and the National
Cancer Institute have for some years been spon-
soring various types of research fellowships to
promising young investigators. Currently, ap-
proximately 200 young scientists each year are
completing programs of advanced training in
some aspects of cancer research. Some of these
are supported as independent investigators for
a limited number of years and a few for the
duration of their scientific careers in order that
thev may devote their entire efforts to cancer
research.

Current support for cancer research covers
practically every possible approach to the study
of this disease — chemotherapy, epidemiology,
virology, immunology, genetics, biology, and bio-
chemistry as well as the uses of hormones, iso-
topes, radiation, and surgery. From one or a
combination of these research efforts, there is
solid justification for a hopeful optimism that
early discoveries will provide the information
necessary for the prevention or cure of cancer.

CANCER CONTROL

The second aspect of a program for the control
of cancer is to secure the utilization of effective
i available measures for its prevention and treat-
ment. It was pointed out earlier that 1 out of 3
persons who are diagnosed as having cancer now
will be saved as compared to 1 out of 4 ten
years ago. In total numbers, this means that
of the approximately 450,000 persons who last
year were diagnosed bv physicians as having
cancer, 150,000 will be saved. This is some 38,000
more than would have survived ten years ago.
This is a magnificent achievement. Yet, it is
estimated that with the knowledge currently

available, it should be possible to increase the
cure rate to 1 in 2 — an improvement which
would mean the saving of approximately 75,000
more lives annually.

Consideration of the deaths from various types
of cancer focuses attention upon some specific
possibilities for the prevention of unnecessary
deaths. For example, the death rates for cancer
of the lung of males 50 to 70 years of age are
50 times as high among smokers using one pack
or more per day as among nonsmokers. After
discontinuing smoking for ten or more years,
the death rates among heavy smokers was 62
per cent less than among a similar group who
continued smoking.

In 1957, 12,000 women died from cancer of
the cervix. Such deaths are practically all pre-
ventable if the disease is diagnosed early and
then adequately treated. Specialists in this field
believe that the widespread use of exfoliative
cytology examinations could lead to the diag-
nosis of practically all of these cancers while in
the curable stage.

Cancer of the breast — another major cause of
cancer deaths among women — last year took the
lives of 22,000 women in the United States. Yet,
in most cases, this disease too can be diagnosed
while still a local lesion susceptible to complete
removal by surgery.

How can such unnecessary deaths be pre-
vented? Obviously, by earlier diagnosis followed
by adequate treatment. Early diagnosis and
adequate treatment depend in part upon the
medical profession and in part upon the public.

The public must be informed about the rela-
tionships of cancers to cigarette smoking, to
certain moles, to chronic irritation, and to certain
other conditions. They must learn the symptoms
which may be suggestive of cancer — the so-

JUNE 1958

271

100,0011
P-pul.t.'
1*»34- 19. "it

AGE

GROUP

100,000

I’opul «l ioi

IT. I- 195ft

10% 20% 30%

INCREASE

ALL AGES

Under 15

15-

24

25-

34

35-

44

45-

54

55-

64

65-

74

75-

64

85 a

Over

18. V I

117. S

-20% -10%

DECREASE

10% 20% 30%

INCREASE

Fig. 1. Per cent change in
cancer death rates by age
and sex in United States
from 1934—1936 to 1954—
1956. Asterisk refers to stand-
ardized rate for age on the
1940 United States Census.
Source: National Office of

Vital Statistics and United
States Bureau of the Census.

Fig. 2. Per cent change in
cancer death rates by site in
United States from 1934 —
1936 to 1954—1956. Asterisk
refers to rate per 100,000
population standardized for
age on 1940 United States
Census. Source: National
Office of Vital Statistics and
United States Bureau of the
Census.

Death Rote*

Site 1954-1956

LIP

stomach
LIVER
UTERUS
MOUTH
SKIN
TONGUE
RECTUM
BLADDER
BREAST
INTESTINES
ALL SITES

prostate

ESOPHAGUS
LARYNX

HODGKIN'S DISEASE
KIDNEY
OVARY
PANCREAS
LEUKEMIA
LUNG

100% '50% 0% 50% 100% 150% 200% 250%

DECREASE INCREASE

Fig. 3. Forecast
deaths if present
tinue.

of cancer
rates con-

272

THE JOURNAL-LANCET

called Seven Danger Signals of the American
Cancer Society:

1. Unusual bleeding or discharge.

2. A lump or thickening in the breast or elsewhere.

3. A sore that does not heal.

4. Persistent change in bowel or bladder habits.

5. Persistent hoarseness or cough.

6. Persistent indigestion or difficulty in swallowing.

7. Change in a wart or mole.

They must present themselves to physicians
promptly when these symptoms occur in addi-
tion to having regular, complete physical exam-
inations with special attention to those areas of
the body particularly susceptible to cancer.

The American Cancer Society’s programs of
public education utilize every available com-
munication medium to reach the public with
pertinent information about cancer. A genera-
tion ago, cancer was an almost unmentionable
disease. Today a large proportion of the popu-
lation speaks freely of cancer, has some under-
standing of it, and has some knowledge of the
“Danger Signals.”

Interest in and knowledge about cancer on
the part of the medical and related health pro-
fessions also have increased substantially in re-
cent years. Examination technics and procedures
for earlv diagnosis are widely employed. Prob-
lems of treatment are approached with skill and
optimism, and adequate facilities for diagnosis
and treatment are becoming increasingly avail-
able.

All of this adds up to substantial progress in

cancer control; yet, much more remains to be
done. Even if research discoveries should pro-
vide completely effective measures of preven-
tion, early diagnosis and treatment today, there
would be a substantial and, in many instances,
a tragic time lapse before these measures would
be generally applied for the benefit of the public.

PROSPECTS FOR THE FUTURE

Estimates by the Statistical Department of the
American Cancer Society indicate that, if pres-
ent cancer attack rates continue, by the year
2000, over a million persons in this country will
be suffering from cancer and 430,000 will be
dying annually (figure 3). This staggering pros-
pect emphasizes the urgency of still more inten-
sive and extensive efforts both in research and
in the effective utilization of available knowl-
edge.

Fortunately, the groundwork has been laid
and the facilities, personnel, and organizations
are available for more rapid progress in these
areas than has been true in the past. To capi-
talize on these, the devoted and continuing par-
ticipation and support of research workers, the
medical and allied professions, health agencies
and organizations, and the public is essential.
With these assured, we can look forward with
real optimism to the more effeetive control and,
we hope, the ultimate prevention of this dread
disease.

Data supplied and graphs prepared by the Statistical
Department of the American Cancer Society.

Heart disease and cancer not only rank highest as causes of death in most
of the highly-developed countries, but they are increasing.

In England and Wales, for example, deaths from cancer in 1947 accounted
for 15.1 per cent of all deaths, but bv 1955, the percentage had risen to 17.6.
Denmark showed an increase from 16.2 per cent in 1947 to 21.8 per cent in
1955, and the United States had an increase from 4.7 to 15.7 per cent.

Deaths from degenerative disease of the heart and arteries are also increas-
ing. Among the possible causes is the aging of the population and consequent
swelling in the 40-to-80 age group in which these diseases are most prevalent.
Also, diagnostic technics have improved, decreasing the number of deaths for-
merly attributed to “senility” or to “unknown causes.

JUNE 1958

273

Annual Health Problems:

A Challenge to Public Health

JAMES H. STEELE, D.V.M.
Atlanta, Georgia

Human and animal health have been inter-
related since the beginning of medical
knowledge. Four thousand years ago, the Baby-
lonian records spoke of the doctors of domestic
animals and of how important their efforts were
in maintaining the health of the animals on
which trade and transportation depended. The
Egyptians likewise realized the importance of
animal health to their society in providing power,
transportation, and food. The priest doctors prac-
ticed their arts both on man and animals. It is
probably not too far-fetched to suggest that the
practical knowledge of animal diseases in ancient
times exceeded that of human diseases because
human medicine was inextricably bound up with
the supernatural.

During the Hippocratic period, knowledge of
animal diseases and their effect on public health
was notably enlarged. The Greek physicians of
this period were the first to describe rabies, an-
thrax, and glanders accurately. Their curiosity
about diseases in dogs, oxen, and horses laid the
basis of comparative and veterinary medicine for
nearly a millennium. They were the first to ex-
amine the organs of diseased animals and at-
tempt to relate these observations with clinical
signs. These examinations led to the formulation
of a pseudoscientific basis for all medicine.

Galen, the most famous of the Greek phy-
sicians in the Roman period, developed preven-
tive medicine and military medicine and was in-
formed on animal-disease problems. His recom-
mendations on the control and prevention of
glanders among military horses by isolation are
still interesting reading to those responsible for
animal health. He established the first animal
hospitals as a part of the Roman military medical

james h. steele is chief of Veterinary Public
Health , Communicable Disease Center, Bureau of
State Services, Public Health Service, Department
of Health, Education and Welfare, Atlanta. He is
also consultant to the World Health Organization,
many universities, research institutions, and medical
groups.

program. Animal quarantine also received his
attention and was applied to all types of animals
that were being returned to Rome from the con-
quered provinces. All of these services were
under the supervision of veterinarians who were
a part of the Roman army medical services. After
the fall of Rome, the practice of veterinary medi-
cine disappeared as an art except among the
Arabic physicians who took the Roman knowl-
edge and gradually enlarged it. They were quite
successful in preventing widespread epizootics
among their animals. Lost in antiquity is the
origin of vaccination, but it is amazing to find
that Arabic shepherds hundreds of years ago
practiced variolation among their sheep Hocks
to control sheep pox, one of the most contagious
and serious animal plagues. After the Moors
conquered Spain, they set up veterinary training
in the various ruling centers. Later, when the
Spanish took over, the Arabic veterinarians and
farriers were retained.

Modern veterinary medicine did not become
established until the middle of the eighteenth
century when the first school or faculty was
founded in Lyon, France. This was followed
within a few decades by veterinary schools all
over western Europe. It was almost a hundred
years before the first veterinary school was es-
tablished in the United States in the 1850’s.

The late nineteenth century was a period of
rapid development in human, comparative, and
veterinary medicine. The infectious disease theo-
ry and subsequent discoveries in bacteriology
provided new tools for the epidemiologists and
public health scientists. The advancements in
the new science of nutrition in human and ani-
mal feeding made society more cognizant of the
value of their animals. Later, the tremendous
expansion of industry and agriculture with the
resulting need for animal power had a very stim-
ulating though short-lived effect on veterinary
medical education. The subsequent replacement
of animal power with mechanical power through-
out the world revolutionized veterinary medical
education and research.

274

THE JOURNAL-LANCET

The objective of modern veterinary medicine
is the protection of animal and human health.
These services are of incalculable value to human
welfare. There are more than 200 infectious dis-
eases of animals, nearly half of which are com-
municable to man under certain conditions.1 The
number of noninfectious chronic diseases with
which animals are plagued is also in the hun-
dreds. The impact of panzootics and epizootics,
or the effect of enzootic disease on the present
world, is forcefully brought to the attention of
man by periodic disease eruptions of such an-
cient plagues as rinderpest in Asia, foot and
mouth disease in Europe, contagious pleuropneu-
monia in Australia, trypanosomiasis in Africa,
brucellosis or tuberculosis in South America, and
anthrax and hog cholera in North America. An
accurate estimate of their effect is difficult be-
cause of the paucity of data on animal morbidity
and mortality and on human diseases and death
due to animal diseases. Nevertheless, there are
some problems which can be used to illustrate
the world wide impact of the zoonoses— tubercu-
losis, brucellosis, rabies, hvdatidosis, and rinder-
pest.

BOVINE TUBERCULOSIS

Bovine tuberculosis was the first animal disease
to be recognized as a public health problem. The
identification of the etiologic agent and its effect
upon human health dramatized its importance
better than any other zoonotic disease. Fifty
years ago, tuberculosis of man and especially of
children was frequently found to be of bovine
origin. In the United States, the Mycobacterium
tuberculosis bovis was stated to be the cause of
5 to 10 per cent of all the tuberculosis seen in
man and as high as 30 per cent of the disease in
children. Estimates of infection rates in ani-
mals varied, but generally it was estimated
that 5 to 10 per cent of the cattle were tubercu-
lous. In some areas, infection rates exceeded 25
per cent and ranged occasionally up to 50 per
cent. This situation required action. Public
health and animal health officials throughout the
nation demanded that this disease be eliminated.
American medical journals and publications of
this period carried innumerable reports about the
disease. Many communities passed regulations
requiring that all milch animals producing milk
for their market should be tested for tubercu-
losis. Minneapolis, your host city, was one of the
first to adopt an animal tuberculosis testing re-
quirement. Later, when pasteurization became
mandatory, the incidence of bovine tuberculosis
in children and adults dropped dramatically in
urban areas. In the rural sections, however, the

disease continued to be a smoldering health
problem which crippled children and adults
developing overt cases.

In 1917, the United States government in-
augurated a national bovine tuberculosis eradi-
cation plan. The plan provided that every bovine
animal in the country was to be subjected to
tuberculin tests and those that reacted were to
be removed from the herd and slaughtered. All
slaughtered animals were subjected to veterinary
meat inspection to determine the extent of the
disease and to determine whether or not any
portions of the carcasses could be used for hu-
man food. The owners of the animals were re-
imbursed in part for their losses by the federal
and state governments.

Within a few years, the benefits from the pro-
gram were realized. By 1940, the estimated in-
fection rate had been reduced to less than 0.5
per cent of cattle tested, which was a reduction
of probably more than 90 per cent. Today the
incidence of infection in tested cattle is even
lower— 0.15 per cent. Bovine tuberculosis is no
longer an important public health or economic
problem in the United States.

The cost of this campaign has been estimated
to have been about 300 million dollars. This is
only a fraction of what the costs would have
been in loss of animal products, meat, milk, and
so forth, if the disease had continued at its 1917
rate for the past 40 years. The monies saved in
animals and animal products alone would total
many billion dollars. The elimination of bovine
tuberculosis as an important childhood disease
cannot be measured. Since 1950, only one proved
case of bovine tuberculosis in children has been
reported. Few human cases of bovine type
tuberculosis have been found in adults during
recent years, and those that have been found

JUNE 1958

275

are usually occupational infections or breakdown
of old lesions.

It is well to point out that this favorable pro-
gress in the control of animal tuberculosis is not
confined to the United States. Canada has re-
duced the disease considerably, and, in some
areas, it has been eradicated. Norway, Sweden,
Finland, and Denmark have all but eradicated
the disease. Finland, in 1955, reported that the
tuberculin reaction rate in cattle was 1 in 10,000,
and investigation of these cases revealed that
they were due to contact with either human or
avian type bacilli.

Great Britain and Holland have also made con-
siderable progress. The Dutch plan is of special
interest inasmuch as it was a joint program of
the health and agriculture ministries to conquer
the disease. In attacking their problem, the
Dutch authorities had veterinarians and phy-
sicians test the animals and the people on the
farms at the same time. They have drastically
reduced the prevalence of the disease in both
animals and man in the rural areas.

Reports from France, Germany, Switzerland,
and Austria indicate that they have undertaken
animal tuberculosis eradication campaigns. Cam-
paigns are also under way in Australia and New
Zealand.

Regardless of the success that has been
achieved, bovine tuberculosis is still a challenge
to be met and vanquished in many parts of the
world. The elimination of this disease will contri-
bute much to the advancement of the well-being
of man. The increase in animal food products
alone will pay for the cost of a program. The
public health benefits are such that no country
can afford not to attack the disease.

BRUCELLOSIS

This entity is probably more widespread than
any other animal disease on earth. It affects more
sheep, goats, and cattle than any other animal
plague. It is also the most important animal dis-
ease communicable to man. Persons ill with this
disease throughout the world are numbered in
hundreds of thousands. Until the advent of the
broad-spectrum antibiotics, it was one of the
most debilitating diseases to which man was sub-
jected. In the United States, the attack rate in
veterinarians was as high as 400 per 100,000. The
highest incidence of this disease in human beings
was recorded in 1947, when almost 7,000 cases
were reported in this country. Since then, there
has been a consistent annual decrease of reported
cases. In 1957, less than 1,000 human infections
were reported.

A campaign to eradicate bovine brucellosis in
the United States, which has been in operation
for a number of years, has been accelerated, and,
since 1953, considerable progress has been made.
By early 1958, 11 states, including Minnesota
and Wisconsin, had become modified certified
areas. This means that cattle in these states have
been tested for brucellosis and fewer than 1 per
cent are reactors. In addition, almost 900 coun-
ties in other states are modified certified areas,
and hundreds of townships have eliminated the
disease from their herds. It is believed that about
one-half of the states will have the infection
under control by 1960, and the entire country
will be relatively free of bovine brucellosis with-
in a decade. Fortunately, there is no sheep or
goat brucellosis problem in the United States.
The goat reservoir of disease was eliminated a
decade ago, and the infection has seldom been
identified in sheep.

Swine brucellosis is a problem, however, es-
pecially in the Midwestern states, both to public
health and animal health. A large per cent of
the occupational type disease in man on the farm
and in the packing house is of swine origin. Con-
trol programs are now getting under way in some
of the hog-producing states. Swine brucellosis
will not be as costly to eliminate as it was in
cattle or will it be as time consuming because
the swine industry is not so widespread. Also, it
is more susceptible to eradication procedures be-
cause an infected swine drove can be sold for
slaughter as soon as disease is identified, with
little or no monetary loss except in the case of
certain pure-bred herds.

This disease should be under control within
the next ten years if the health and agriculture
authorities give it the same support as they are
giving the bovine brucellosis eradication pro-
gram. Elimination of swine brucellosis will yield
many economic and public health benefits. The
control of the disease will remove an important
cause of many illnesses among pigs. Of bene-
fit to public health will be the fact that the
major cause of occupational brucellosis would
he erased.

In the control of brucellosis, the Scandinavian
countries have set the pace. Denmark, Norway,
Sweden, and Finland have all but eradicated the
infection from their animals. Great Britain, Hol-
land, Germany, Switzerland, and Austria are also
making progress. In Spain, WHO is carrying out
a sheep vaccination study to determine if this
would be an effective control procedure. Many
other countries are also supporting research on
brucellosis control methods. No area having this

276

THE JOURNAL-LANCET

disease in its animal population can afford not
to seek methods to eradicate it.

HABIES

Rabies is an example of an animal health prob-
lem which is rightly of much more concern to
public health officials than it is to agriculture
authorities. The very name has stricken the
minds of men with terror for thousands of years.
The communicability of the disease to man from
biting dogs, wolves, foxes, and skunks has been
known for centuries. Rabies is present through-
out all the large continents of the world— North
and South America, Europe, Africa, and Asia.
Fortunately, it has never occurred in Australia,
New Zealand, Oceania, or Hawaii. It has been
eradicated in a number of areas, including west-
ern European countries and some West Indian
islands.

Animal mortality due to rabies varies consider-
ably throughout the world. In the United States,
a ten-year summary reveals that all warm-
blooded animals are susceptible. The dog is the
animal most frequently affected, but, in recent
years, canine rabies mortality has steadily de-
clined, while that of the wild animals and farm
animals has increased. The decline of rabies in
dogs is attributed to the national rabies control
campaign based on good local dog control and
effective canine rabies vaccination. Canine rabies
will no doubt eventually be brought under con-
trol in urban areas by these methods. This will
eliminate or reduce the hazard of exposure to
rabid animals for more than 80 per cent of the
population except for those visiting rural or
recreational areas.

Animal bites are second only to automobile
accidents as a cause of nonfatal accidents in our
country. A recent survey of animal bites re-
vealed that dogs are by far the most frequent
offenders. Furthermore, the survey showed that
over a twentv-month period, 25 per cent of
children under 10 years of age in the area sur-
veyed were bitten. It is estimated that every
year more than 2 million people are bitten by
animals and that about 50 thousand of these re-
quire antirabies vaccination treatment. The val-
ue of vaccine therapy is demonstrated by the
low-death rate from rabies in human beings.
During the past decade, the death rate has fallen
precipitously, and, in 1957, only 6 fatalities were
reported in the United States.

Western Europe, including the Scandinavian
countries, has set an effective example in the
eradication of rabies. Norway and Sweden have
been free of the disease since the late nineteenth
century, as has Great Britain since the turn of

the century except for a short-lived introduction
after World War I. During World War 11, rabies
was rampant on the Continent, but, within a
few years after the reestablishment of civilian
governments, France, Belgium, Holland, and
Switzerland eliminated it. Denmark and Fin-
land have also eradicated the disease except for
occasional outbreaks in the areas bordering on
East Germany and Russia. Farther east, Poland
and Czechoslovakia have had success in reducing
canine rabies incidence, but these countries also
have wildlife reservoirs. Russia reports success-
ful results from canine rabies immunizing con-
trol methods.

Unfortunately, there are many areas of the
world where the dog is held in such low esteem
that no efforts to control its numbers are prac-
ticed. Other reasons for lack of control programs
include various cultural attitudes and lack of
funds to obtain vehicles, train personnel, and
establish dog impoundments where the animals
can be put to death by euthanasia. WHO has
assisted some countries in developing control
programs. In Malaya, Israel, Southern Rhodesia,
and Japan, all areas where rabies had become
enzootic, control campaigns have been successful.

Such demonstrations have stimulated health
authorities in other countries to re-examine their
policies. There is no doubt of the effectiveness
of good dog control and vaccination in reducing
rabies in any region, and these measures can
sometimes lead to virtual eradication of the
condition if the wild animal reservoir is not ex-
tensive or important. The bat rabies situation,
now under studv in parts of North America as
well as some areas of South America, has intro-
duced a new potential in the maintenance of the
virus. The bat disease has also been found in
West Germany and Yugoslavia. The dog, how-
ever, is still the most important source of infec-
tion for man, and it behooves all health authori-
ties to intensify their canine rabies control plans.

HYDATIDOSIS ("ECHINOCOCCOSIS )

Hydatid disease is a major public health problem
on nearly all the continents. The Mediterranean
basin has the highest prevalence, followed by
southern Latin America, Australia, and New Zea-
land. The hydatid or cyst form of the disease
affects man, swine, dogs, cats, and rodents and
herbivorous and wild animals. The tapeworm
form is found only in dogs, wolves, and other
members of the canidae family. The adult para--
site has little effect on the dog. Man is suscep-
tible only to the hydatid form of disease, which
results from the ingestion of eggs passed by-
canine hosts.

JUNE 1958

277

The public health aspects of the disease far
exceed the economic effects. The cvsts in animals
seldom interfere with their well-being. Most food
animals are slaughtered before the developing
cysts reach such a size as to cause trouble in
the host. Ninety per cent of the cysts found in
cattle and 20 per cent found in pigs are sterile.
Sheep cysts are the most dangerous in the spread
of disease to the subsequent host as less than 10
per cent of the cysts are sterile. In man the
cysts have the opportunity to grow for many
years and eventually interfere with the functions
of the organs in which they are located. As they
increase in size, they also develop daughter cysts
which may disseminate the infection further. In
some instances, the disease is so widely dissemi-
nated within the individual that he succumbs
within months after the original exposure. On
the other hand, some cysts develop so slowly that
signs and symptoms do not appear until decades
later.

In the United States, less than 1,000 cases have
been reported since 1900. Most of the cases
were in persons who had emigrated from Medi-
terranean countries. The disease occurs occa-
sionally in domestic animals in the United States,
such as swine, cattle, and sheep. The parasite
has fortunately not been able to establish itself
in the dog population, and, hence, there is little
transmission of the disease to human beings in
this country.

Control of the disease in man is based on
elimination of the parasite in dogs. This is done
through rigid dog control and repeated treatment
of resident or work dogs. Probably just as impor-
tant is preventing infection by prohibiting the
feeding of infected tissues to dogs. Diseased,
raw lungs and livers are often fed to dogs along
with other offal when animals are slaughtered.
If offal is to be used for dog food, it should be
boiled. In areas where canine infection rates are
high, dogs should not be allowed in households
nor should they have any contact with children.
Human beings may easily be infected by fond-
ling and petting infected dogs.

The challenge of control is similar in many
ways to dog control in connection with rabies.
Effective dog reduction is difficult without full
support of the public. An outstanding example
of disease control was carried out in Iceland
some years ago. In 1900, it had been estimated
that between 35 and 50 per cent of the popula-
tion was infected with hydatid cysts. At that
time, something like 22,000 dogs were kept by
the 70,000 people. This amounted to one do<r
to each three persons, compared to the United
States’ ratio of 1 dog to 8 persons. Following an

intensive dog control plan drastically reducing
the number of dogs, the disease decreased in
man and today it is quite rare in Iceland. Aus-
tralia and New Zealand have also made progress
in reducing hydatid disease through education,
dog control, and prohibition of feeding raw offal
to dogs. Argentina and Uruguay are making
efforts to eliminate the infection. It is a problem
that deserves more attention than it sometimes
receives from sanitary officials and agencies in
endemic areas. A national dog control program
in those areas would be one of the most economi-
cal approaches to control. The gains from eradi-
cation of hydatid disease are such that no one
can wisely pass the problem by, even temporar-
ily.

RINDERPEST

Rinderpest or cattle plague occurs only in cattle.
It is presented here as an example of an animal
disease that does not have a direct effect on pub-
lic health but indirectly may have serious conse-
quences. It is an acute febrile disease of rumi-
nants characterized by a rapid course and a hffih
mortality rate. Diarrhea, ulcerations, and sub-
mucosal hemorrhages are common signs. It has
plagued livestock for centuries, and, on occa-
sions, it has destroyed the wealth of many fami-
lies, tribes, and even nations.

The disease is enzootic in Asia and parts of
Africa. It has spread from Asia to Europe on
many occasions in the past, especially in time
of war. The results of these epizootics have been
devastating. During some invasions, a large por-
tion of the cattle population of eastern Europe
perished. One of the most dramatic panzootics
of modem times was the introduction of the dis-
ease to South Africa in the 1890’s where it swept
through the ruminant population like a prairie
fire. Millions of cattle and wild animals died
during the period between 1889 when it first
appeared and 1898 when it was checked. The
plague is now enzootic in East Africa among
game animals. Considerable progress has been
made by the British Veterinary Service in elimi-
nating rinderpest in some areas. It was an-
nounced recently that all of Tanganyika is ap-
parently free of the infection.

The effect upon commerce and human welfare
is well illustrated by the epizootics which were
reported in China and southeast Asia during
World War II. An epizootic in Laos from 1944
to 1945 destroyed 75 per cent of the cattle and
buffalo. This epizootic also spread to the neigh-
boring countries and caused similar devastation.
The effect in these countries is measured not
only by the loss of animal food products but also

278

THE JOURNAL-LANCET

TABLE J

ANIMAL POPULATIONS'
1954-1955

South

America

North

America

Europe

Asia

Africa

Australia

Oceania

Cattle

147°

134

39

280

101

16

6

Swine

47

70

95

113

4

1,3

1

Fowl

45

485

552

250

87

1.2

Horses, mules, asses

26

15

20

36

14

.8

.2

Sheep

121

39

129

177

133

131

40

Goats

22

14

22

166

10

2

Totals

408

757

857

1,022

349

149.1

48.6

°In terms of millions.

TABLE 2

HUMAN POPULATIONS'

Asia

1,481,000,000

Africa

220,000,000

Australia

9,400,000

Europe

411,000,000

North America

238,000,000

South America

124,000,000

by the loss of animals used to work the fields
and move rice from the farms to shipping points.
The lack of transportation in these areas had far-
reaching effects. There was a rice shortage in the
urban areas which was quite acute. This resulted
in poor human nutrition with subsequent public
health problems.

Progress has been made in the control of rin-
derpest in the past decade. Much improved
vaccines have been developed and are being
widely used. The establishment of national
veterinarv services in areas where the disease is
enzootic has contributed to its control. A cam-
paign to eradicate rindeq^est has been under-
taken by many countries in Asia and Africa. The
United Nations’ Food and Agriculture Organiza-
tion as well as the postwar UNRRA and the Brit-
ish Veterinary Service have effeetivelv demon-

strated the value of control measures. The even-
tual control and eradication of rinderpest will
contribute considerably in raising the standard
of living of many people.

CONCLUSION

The animal population of the world ( table 1 )
must keep pace with the human population
( table 2 ) to improve the standard of living of
man, including human nutrition, and public
health. To insure a healthy animal population,
improved veterinary medical services are needed
in many parts of the world, with diagnostic
services, educational centers, and facilities for
research and training of ancillary personnel to
carry out disease control operations. In addition,
public health leaders must develop counterpart
public health programs to prevent the spread of
animal diseases which are frequently transmis-
sible to man and, in some respects, more impor-
tant as public health problems than they are as
animal health problems. The problems that con-
front the greater medical field in comparative
medicine, pathology, and epidemiology are fur-
ther challenges to all concerned. The need for
medicine to have close liaison with all its
branches, especially veterinary medicine and
public health, is paramount in advancing health
of all men.

REFERENCES

1. Joint WHO/FAO Expert Group on Zoonoses, WHO Technical
Report Series No. 40, May 1951.

2. Park, W. H., and Krumwiede, C.: Relative importance of

bovine and human types of tubercle bacilli in the different

forms of tuberculosis. J. Med. Res. 27:109, 1912.

3. The World Almanac, 1957.

4. Food and Agriculture Organization year book, 1956.

JUNE 1958

279

Stress ia the World, the Individual
and the Doctor

HOWARD A. RUSK, M.D.

New York City

One of the distinguished features of social
development in the past decades is the in-
creasing recognition throughout the world that
the security and welfare of one part of the world
is dependent upon the security and welfare of
each other part of the world.

Some of this recognition has been forced upon
us by the technologic advances of the twentieth
century which have created a shrinking world
in terms of communication, transportation, and
trade and the devastating effects of modern
weapons of warfare. Mankind through the ages
has been forced to develop social concepts to
fit the realities of his changing environment.

The concept is shared by the great majority
of the people of the world, regardless of their
race, relations, nationalities, or professions, that
this growing recognition of mutual dependence
has not resulted from practical necessity alone.
It also represents the ability of a maturing so-
ciety to give fuller expression to a feeling that
is as old as mankind itself — the desire to share
with and to help one’s neighbor.

This concept is present to more or less degree
in all persons, but particularly in physicians. It
is the primary motivation which causes a young
man or woman to enter medicine and continues
to be the guiding force throughout his profes-
sional life.

The people of the world have matured very
slowly socially, but, at the same time, we have
aged chronologically and physiologically much
more rapidly. Two thousand years ago, the av-
erage person lived to be 25 years of age. By
1900, the life span was 49 years; by 1950, 67
years; and, in 1957, it reached the legendary
three-score-and-ten.

As a result of this lengthening of the span,
today in America more than 28,000,000 of our

Howard a. rusk is professor and chairman of the
Department of Physical Medicine and Rehabilitation.
New York U niversity-Bellevue Medical Center.

Paper presented March 27, 1958, at The Doctor
and His Practice forum sponsored by the District
Council of the Washington Metropolitan Area and
The Wm. S. Merrell Company , Cincinnati.

fellow citizens are suffering from chronic disa-
bility. Staggering as this is, we can expect it
to increase in the future; for, as our population
continues to grow older, the incidence of chronic-
illness and its resultant physical disability will
continue to increase correspondingly.

Contrary to the opinions expressed by some,
this growing incidence of physical disability in
our nation is a tribute rather than an indictment
of American medicine. Advances in medicine
have been one of the primary factors, along with
improved nutrition, increased education, and
better housing and all the contributing factors
to our unprecedented current standard of living.

The skills of our physicians mean that thou-
sands of Americans are alive today who would
have died at the turn of the centurv with the
same medical problems. Yet, many have not come
out unscathed. They have survived only to find
themselves confronted by residual physical dis-
ability. We, as physicians, have helped to create
this problem; we, as physicians, bear primary
responsibility for leadership in its solution.

These two parallel social phenomena of the
past two decades — global interdependence and
increased incidence of physical disability — have
a mutual genesis in the tremendous scientific and
technologic advances of this period. But there
is a common denominator in both the corres-
ponding but slower development of social ma-
turity in which the democratic societies of the
world place increasing value on human worth
and the dignity of the individual.

During the past fifteen years, I have been pro-
fessionally identified with rehabilitation — the
third phase of medicine which takes the patient
from the bed to the job and the branch of medi-
cine primarily concerned with helping the dis-
abled physically, emotionally, and sociallv to
achieve the best life possible within the limits
of their disabilities. The basic concept of re-
habilitation is replacement of the passive con-
cept of convalescence, in which time and nature
take the place of the physician, with a concept
of dynamic active rehabilitation built around the
fulfillment of not only medical, but also emo-

280

THE JOURNAL-LANCET

tional, social, and vocational needs of patients.

Our experience in this program of rehabilita-
tion has changed the concepts which many of us
have had about stress. In its usual connotation,
stress implies strain. We frequently forget that
stress also applies to the adaptation and stimu-
lation that culminate in the fulfillment of the
goals and ambitions of the patient which are
expressed in his personality.

Man sets his goals to the stress point. If he
does not use his full potentials, he vegetates; if
he goes from stress to strain, he breaks. But, if he
can either by himself or with proper guidance
find the perfect blend or end point of his per-
sonal stress, his life is satisfactory and rewarding.

It has recently been shown in a careful study
of 250 patients, with an average age of 63 who
have had strokes of apoplexy, that the severity
of the stroke had no correlation with the success
of rehabilitation. If the patient had work to do,
a home to which he could go, and someone to
love and love him, regardless of the severity of
the disability, the results were good. Certainly,
this can be said of patients in surgical conva-
lescence. The desire to live and not just to he
alive is fundamental in the physical, emotional,
and endocrinologic factors so important in im-
munologic and anabolic victories over degenera-
tive processes.

There is a parallel between the personal ex-
periences all of us have with stress, both as an
enemy and a beneficent friend, as seen in our
patients and the stress that marks our interna-
tional relations. The problem we face in our de-
sire to find a method of working toward world
peace is to concentrate first on areas in which
we of the democratic western nations and those
of the communistic eastern nations can agree.

Those of us in medicine have long recognized
that medicine knows no barriers ef geography,
nationalism, language, or religion. Through our
international professional organizations and the
World Medical Association and our support of
the World Health Organization, we have given
expression to this belief.

Today, there are exciting prospects that others
are joining us in this belief. In his sixth State of
the Union Message, President Eisenhower made
a bold proposal of an international “Science for
Peace” plan to attain “a good life for all.” As a
first step in such a program, the President invited
the Soviet Union to join the current five-year
program for the global eradication of malaria.
This is a $515,200,000, coordinated program
being conducted by WHO and various individ-
ual nations. The United States is contributing
$108,400,000 of its cost over an eight-year pe-

mm

riod. The President then stated our willingness
to pool our efforts with the Russians in other
campaigns against cancer and heart disease. “If
people can get together on such projects,” he
asked, “is it not possible that we can then go
on to a full-scale cooperative program of science
for peace?”

Almost each successive week since, there has
been some action toward the implementation of
President Eisenhower’s proposal. Senator Lister
Hill of Alabama, long the dean of our American
health legislators, almost immediately announced
his intention to introduce specific legislation for
a “Health for Peace” program. Our Department
of State has announced plans for a limited ex-
change of scientific and medical personnel. In-
creasing numbers of Soviet and eastern Euro-
pean physicians are coming to our medical meet-
ings. A new program of voluntary medical aid
known as Medico has been announced to send
teams of physicians and medically trained as-
sistants into the underdeveloped areas of the
world where they will build, equip, and staff
medical clinics and hospitals. Medico is a real
people-to-people concept carried out at the grass
roots through a physician-to-patient program.

In the last few months, the attention of the
world has been centered on satellites and mis-
siles and the battle for the control of cuter
space. In this battle, international stress has
passed the world’s end-point and has become
strain. But, today, through international med-
ical cooperation, our stress can find an outlet in
the far more important battle - the battle for
the control of inner space — the inner space in
the minds and hearts of mankind through the
world. We in medicine have an unbelievable
challenge and an unbelievable opportunity to
provide leadership in this most important battle.

JUNE 1958

281

Rehabilitation of the Disabled

FRANK H. KRUSEN, M.D.
Rochester, Minnesota

In recent years, physicians and health work-
ers throughout the world have become seri-
ously concerned with the problem of rehabilita-
tion of chronically ill persons. There has devel-
oped a world-wide, mass sociologic movement
directed toward rehabilitation of these individ-
uals. Here in the United States, the President’s
Ccmmission on the Health Needs of the Nation
has defined rehabilitation as “the restoration,
through personal health services, of handicapped
individuals to the fullest physical, mental, social,
and economic usefulness of which they are capa-
ble including ordinary treatment and treatment
in special rehabilitation centers.” Our famous
American elder statesman, Bernard M. Baruch,
has said, “The investment in rehabilitation is
an investment in the greatest and most valuable
of our possessions, the conservation of human
resources.” The delegates to the World Health
Organization, holding their annual meeting in
Minneapolis, Minnesota, will undoubtedly be
concerned with this new and important inter-
national philosophic approach to the solution of
the rapidly developing problems of chronic ill-
ness.

Chronic illness is increasing enormously
throughout the world, and international health
workers should foster a movement to urge their
medical associates in every land to abandon an
attitude of passive acceptance and neglect of
chronic illness and substitute an attitude of op-
timism and vigorous, dynamic physical, mental,
social, and economic rehabilitation, thus achiev-
ing great benefits to chronically sick and dis-
abled persons in all countries.

The world problem of rapidly increasing
chronic illness is a major one, and it deserves as
much, if not more, consideration as do the prob-
lems of acute illness. Until recently, physicians
throughout the world have tended to devote

frank h. krusen is head of the Section of Physical
Medicine and Rehabilitation at the Mayo Clinic and
professor of physical medicine and rehabilitation in
the Mayo Foundation, Graduate School, University
of Minnesota.

their major attentions to the causes, diagnosis,
and cure of acute diseases. Efforts in this direc-
tion have been outstandingly successful. For
example, in the United States, the life span of
the average person has been extended from 49
years in 1900 to approximately 70 years today.
Thus, in the United States, the life expectancy
of people who have reached 65 years is still
another 13.9 years. This indicates that problems
of chronic illness will increase and will be of
long duration. Because of the improvement in
the management of acute illness, international
health workers find now that they have produced
for themselves a whollv new group of problems
in relation to chronic illness. Our success in post-
poning death has led to the necessity for man-
agement of an ever increasing number of serious
disabilities.

Chronically ill and seriously injured persons
have been saved from death, but there can be
worse things than death. It may be much more
humane to provide services which will save dis-
abled persons from years of dependency than to
save their lives. The modern team approach to
helping seriously handicapped persons attain the
fullest possible self-sufficiency is now being de-
veloped at certain key centers in the United
States in an extremely interesting fashion. In

282

THE JOURNAL-LANCET

such key rehabilitation centers, trained medical
specialists in physical medicine and rehabilita-
tion work with specialists in many other fields of
medicine; physical, occupational, and speech
therapists; social workers; and vocational coun-
selors to restore seriously handicapped persons
to the fullest degree of self-respect and self-
sufficiency.

In the state of Minnesota, there are at present
three such complete rehabilitation centers — the
Department of Physical Medicine and Rehabili-
tation at the University Hospital in Minneapolis,
the combined Kenny Institute and Curative
Workshop in Minneapolis, and the Section of
Physical Medicine and Rehabilitation at the
Mayo Clinic in Rochester. These centers strive
to take the patient from his bed and return him

to the fullest possible activity of which he is
capable. The variety of workers in such centers
provide for physical and psychologic rehabilita-
tion, prevocational evaluation, sheltered employ-
ment, and, finally, arrange for vocational train-
ing and placement of handicapped persons when
necessary. Today international health workers
can well consider the slogan that it is the phy-
sician’s responsibility “not only to add years to
life but also to add life to years,” and they may
well remember the definition given by that re-
markable woman. Miss Mary E. Switzer, Director
of the United States Office of Vocational Re-
habilitation, who said, “Rehabilitation is a bridge
spanning the gap between uselessness and use-
fulness, between hopelessness and hopefulness,
between despair and happiness.”

During the last ten years, accidents have become a serious and often
leading cause of death, particularly among children and adolescents. In North
America and in parts of Europe, accidents account for nearly one-half of all
deaths among bovs between 5 and 9 vears of age. Road accidents claim most
young lives; then come falls, which in some countries are responsible for up
to one-third of all accidental deaths; then drowning, fire, explosions, and
poisoning.

JUNE 1958

283

Minnesota Shares in Professional Education
for Better Health

GAYLORD W. ANDERSON, M.D.
Minneapolis, Minnesota

Elsewhere in this issue of the Journal-
Lancet, Dr. Grzegorzewski has described
the important role played by WHO in promo-
tion of professional education. The readers of
this article may wonder what role the Univer-
sity of Minnesota is taking to share its technical
knowledge and skills with other nations and to
what extent the University benefits from this
program.

It should be emphasized at the outset that
WHO is not the only agency interested in the
international promotion of professional training
in the health sciences. To be sure, it is the
largest and, because of the wide distribution of
its membership, the most comprehensive in its
coverage. Similarly, it is the most varied in its
approach, for, as a multilateral agency, it is in
a position to provide educational opportunities
in any country where such training facilities
exist. Thus, the students who are brought to the
United States represent only a fraction of the
total who may be assigned for study in other
countries. Wherever training facilities exist there
mav be found an international student body
assembled under WHO auspices.

Mingled with the WHO trainees brought to
the United States, however, we will find stu-
dents whose period of study is provided bv the
International Cooperation Agency as a part of
its bilateral program for help to other nations.
Other students are supported by their respective
governments or by one of the foundations, such
as the Kellogg Foundation, the Bureau for Med-
ical Aid to China, the American-Korean Founda-
tion, or the Near-East Foundation. The entire
list of agencies which have included support of
professional education as part of their programs
is too long to be recorded here. However, spe-
cial note should be made of the Rockefeller
Foundation which directed its attention to this
program earlv in the century and essentially pio-

gaylord w. anderson is Mayo professor and di-
rector of the School of Public Health at the Uni-
versity of Minnesota.

neered its development long before the creation
of WHO or ICA. Many of the WHO delegates
attending this assembly are persons whose earlv
professional training in public health was made
possible by this Foundation through its former
International Health Division.

As one of the educational institutions to which
WHO and other agencies send students for ad-
vanced professional education, the University of
Minnesota has an opportunity to share its facili-
ties with other nations. Each year physicians,
nurses, and other health personnel come to Min-
nesota from all corners of the globe to earrv on
advanced studies in their respective fields. Even
school of the College of Medical Sciences, every
department of the Medical School, and even-
component of the Mayo Foundation have par-
ticipated in this program to varving degrees.
Graduates and former students are scattered
throughout the world, many occupying positions
of major responsibility in their respective coun-
tries, many engaged in teaching, and others in
governmental posts.

Since WHO is essentially a health organization
and, as such, has given special attention to train-
ing of personnel to occupy responsible positions
in their respective health ministries, a look at the
foreign students in the School of Public Health
may serve as a good example of what one part
of the University contributes to the international
health program. Since the end of World War II.
278 students from nations other than the United
States have been enrolled in the school for grad-
uate training. All have had basic professional
training in their respective countries, occupied
positions of varving degrees of responsibility in
their homelands, and have come to this country
to learn more about public health that can be
applied to the solution of their own problems.
Included in this group have been 72 physicians,
57 public health nurses, 56 engineers, 29 health
educators, 24 statisticians, 19 hospital administra-
tors, 15 veterinarians, and 1 dentist and 5 in other
health fields. Of them, 50 have been supported
by WHO and 137 by ICA or its predecessors.

284

THE JOURNAL-LANCET

Students have been enrolled from 54 nations or
areas in all — Afghanistan, Argentina, Bolivia,
Brazil, Canada, Ceylon, Chile, China, Colombia,
Costa Rica, Cuba, Denmark, Dominican Repub-
lic, Ecuador, Egypt, El Salvador, England, Fin-
land, Formosa, Germany, Greece, Guatemala,
Haiti, Honduras, India, Indonesia, Iran, Iraq,
Israel, Italy, Jamaica, Japan, Jordan, Korea, Leb-
anon, Liberia, Mexico, Nevis, New Zealand,
Nicaragua, Norway, Pakistan, Panama, Peru,
Philippine Republic, Sweden, Switzerland, Tan-
ganyika, Thailand, The Netherlands, Turkey,
Uruguay, Venezuela, and Yugoslavia.

The various other components of the College
of Medical Sciences could similarly point to their
records of foreign students, as could also each
of the other 10 schools of public health in the
United States. In the School of Public Health at
Minnesota, we are proud of the part that we
have been permitted to play in this educational
program, and we recognize with due humility
that we are but one part of the University that
is performing this function and that Minnesota
is but one of many universities that is making
its facilities available for world-wide education
in the health sciences.

All of the program is not, however, carried
on within the academic halls of the University
or the hospitals and health agencies that serve
the community. Education is a two-way street.
Staff members of the School of Public Health
and other parts of the College of Medical Sci-
ences have participated actively in teaching mis-
sions in other countries or have served in con-
sultant capacity to WHO or ICA in various
phases of their educational programs. Others
have benefited from opportunities to study or
observe health programs in other countries, thus
enriching their knowledge of the problems and
conditions to which their students will return
upon completion of their studies in this country.

No sketch of the University’s contribution to
international education in the health field would
be complete without mention of the special pro-
gram of assistance to the National University
of Seoul in Korea. In 1954, the University signed
a contract with ICA to assume special responsi-
bilitv to aid the National University of Seoul in

re-establishing and strengthening its programs in
medicine, agriculture, and engineering. This pro-
gram, financed by ICA but conducted under
University auspices, has provided for the send-
ing of staff to Korea to serve as faculty advisers
and, more important, for the bringing of Seoul
faculty to Minnesota for varying periods of grad-
uate study and observations of methods of pro-
fessional education. Since the inception of the
program, 36 members of the Faculty of Medicine
of Seoul have spent periods of study at the Uni-
versity ranging from six months to three years.
Simultaneously several members of the Univer-
sity staff have spent varying periods at Seoul,
and the University has handled a program of
purchase of equipment to replace much of what
was lost or destroyed in the period of hostilities.

Again, it must be emphasized that Minnesota
is not unique in its contribution to international
education in the health sciences. Neither health
nor knowledge recognizes political boundaries.
Universities everywhere share in this privilege
of participating in a global program of exchange
of human knowledge. Just as we in Minnesota
share our knowledge with others so others share
their learning with us as do universities, hos-
pitals, and medical installations throughout the
world, each making its contribution toward
better international understanding and better
health.

JUNE 1958

285

Non-Venereal Syphilis: a Sociologi-
cal and Medical Study of Bejel,
by Ellis Hernlon Hudson,
M.D., 1957. Baltimore: Williams
and Wilkins Co., 212 pages, 91
figures. $7.00.

This monograph is based upon an
earlier phase of the author’s life
when, for nearly seventeen years, he
was a resident of Lebanon and Me-
sopotamia. He and his wife set up
their home on the Euphrates River
thirty-four years ago, and his first
paper on bejel, the non- venereal
syphilis of the Bedouins, appeared
in 1928.

The present hook grew out of the
many papers written by the author
on this subject in the intervening
years and from a statistical study of
the bejel cases which he made under
the auspices of the research section
of the United States Public Health
Service in 1955.

The subtitle indicates that the
hook is of sociologic as well as med-
ical interest. He describes the dif-
fering impact of syphilis upon three
different social groups all living in
the same isolated area. He shows
that under primitive conditions,
syphilis is a non-venereal infection
among the children but gradually
becomes venereal in adults as com-
munity hvgiene improves. There is
an interesting chapter in which this
ecologic approach is applied to the
question of the origin of syphilis.

The author boldly attacks the con-
troversial question of the relation-
ship between syphilis and yaws and
brings forward the present evidence
that they are both caused by the
same parasite, Treponema pallidum,
and advocates the inclusive name
“treponematosis” for both. He uses
bejel as an illustration of endemic
syphilis which bridges the gap be-
tween venereal syphilis and yaws,
and he indicates that endemic syph-
ilis is intermediate in respect to his-
toric evolution, epidemiology, clin-
ical appearance, serology, patholo-
gy, and experimental biology. The
treatment of the three forms of
treponematosis is identical.

The underlying philosophy of this
hook is in line with today’s disease
concepts. It deals with a geographic
area that is in this morning’s head-
lines; among other things, it touches
on tropical medicine, venereal dis-
ease control, anthropology, the ge-
ography of disease, and suggests a
revision in conventional thinking
about social hygiene.

It seems that bejel can hardly be
dismissed as a local and exotic dis-
ease of slight importance to the

BOOK

REVIEWS

American reader. This is a unique
story of a personal experience, and
it deals with important matters.
Above all, it is interesting reading.

j. Arthur Myers, M.D.

•

Ankylosing Spondylitis, by j. Fores-
tier, M.D., F. Jacqueline, M.D.,
and J. Rotes-Querol, 1956.
Springfield, Illinois: Charles C

Thomas. $10.75.

The English edition of this volume
has been translated from the origi-
nal French edition that was pub-
lished in 1951. It is directed toward
the presentation of a type of rheu-
matic syndrome that is considered
by these French authors to be a
true, clinical entity separated en-
tirely from rheumatic heart disease
and rheumatoid arthritis. Such opin-
ion does not receive acceptance bv
most English and American students
of this disease who, in turn, feel that
it represents a variant of rheuma-
toid arthritis. However, the basis
on which these investigators have
formed their distinctive evaluation
appears to have a devoted tendency
to isolate this rheumatic-like com-
plex into a separate clinical entity.
The study is based on a series of
some 200 patients with ankylosing
spondylitis with various symptoma-
tology and, at times, rather bizarre
complaints. Actually, in reading the
volume, it seems that any type or
obscure form of arthralgia could de-
velop into a full-blown case of an-
kylosing spondylitis. This had been
the source of controversy with the
American rheumatologists who have
seen similar prodromal symptoms
turn into acute rheumatic heart dis-
ease or, later, become manifest as
chronic, disabling rheumatoid ar-
thritis with pronounced peripheral
involvement. The book does have
considerable merit in that it pre-
sents views which are apparently
based on expert clinical judgment.
Readers will find a satisfactory his-
toric background for the many
synonyms and rather unusual des-
ignations from the clinical stand-
point that this entity has received.

The subject is well-covered with
a complete evaluation of the disease
based on spinal, extra-articular, and
peripheral symptomatology in its in-
sidious onset. The pathologic anato-
my is well-defined and is further
aided by photographs of dry speci-
mens and radiographic reprints.
Photomicrographs are also used to
an advantage, and a review of treat-
ment is included.

The format of the book is good,
allowing those interested in the sub-
ject to review the entire concept of
the disease from its origin to the
present-day methods of therapy.
The iritis and ocular manifestations
that may occur have been presented
so that the clinician becomes aware
of this manifestation as an obscure
symptom of the onset of the disease.

It is obvious, however, that a pre-
cise description of the ankylosing
spondyitis has not been established
and that we must endeavor through
clinical observation and basic re-
search to separate, if possible, these
various entities. The book is highly
recommended to those who are in-
terested specifically’ in this condi-
tion. It is also worthwhile to others
in ancillary specialties, such as or-
thopedic surgery, rehabilitation, and
diseases of childhood. General phy-
sicians, rheumatologists, and intern-
ists will enjoy its content.

Harvey O’Phelan. M.I).

•

Diseases of the External Ear, by
Ben H. Senturia. M.D., written
with the assistance of Carl F.
Gessert, Ph.D., Morris D. Mar-
cus, M.D., Bernard C. Edler,
M.D., Fritz M. Liedmann, M.D.,
LAyVRENCE H. Sophian, M.D..
Charles D. Carr, M.T., and
Elizabeth S. Baumann, A.B.,
1957. Springfield, Illinois: Charles
C Thomas, 214 pages. $8.50.

This volume fills a real need in oto-
laryngological literature. No one has
appreciated this void more than the
author. While Dr. Senturia was
serving in the armed forces in 1942.
he recognized the great confusion in
diagnosis and the conflicts in meth-
ods of treatment of the severe fun-
gus infection of the external ears
seen so frequently in the exposed
troops. This was especially true of
the cases seen in the southern Unit-
ed States and in the South Pacific.

Dr. Senturia’s interest was stimu-
lated to such an extent that, for the
past fifteen years, he has made a
detailed study of this problem. This
book is a comprehensive report of
his extensive experiments and tests
( Continued on page 40A )

286

THE JOURNAL-LANCET

release from pain and inflammation

With BUFFERS IN ARTHRITIS

salicylate benefits with minimal salicylate drawbacks

Rapid and prolonged relief— with less intolerance.

The analgesic and specific anti-inflammatory action of Bufferin helps
reduce pain and joint edema— comfortably. Bufferin caused no gastric dis-
tress in 70 per cent of hospitalized arthritics with proved intolerance to
aspirin. (Arthritics are at least 3 to 10 times as intolerant to straight aspirin
as the general population.1)

No sodium accumulation. Because Bufferin is sodium free, massive dosage for
prolonged periods will not cause sodium accumulation or edema, even in
cardiovascular cases.

Each sodium-free Bufferin tablet contains acetylsalicylic acid, 5 grains, and the antacids
magnesium carbonate, IV2 grains and aluminum glycinate, $4 grains.

Reference: 1. J.A.M.A. 158:386 (June 4) 1955.

ANOTHER FINE PRODUCT OF BRISTOL-MYERS

Bristol-Myers Company, 19 West 50 Street, New York 20, N. Y.

39A

BOOK REVIEWS

( Continued from page 286 )

conducted under the auspices of the
Army Medical Department. He
made subsequent studies as a prac-
ticing otolaryngologist and teacher
in the department of otolaryngology
at Washington University, St. Louis.

In many respects, some of the
chapters in this work may be too
detailed for the average reader to
enjoy or find useful. The sections on
Animal Experiments, Chemistry and
Prophylaxis of External Otitis are in
this category. However, for the seri-
ous student and investigator, these
chapters will be very rewarding.

The comprehensive extent of this
volume may be shown by listing the
chapter headings: 1. Introduction,

2. Factors considered responsible
for External Otitis, 3. Anatomy and
Histology, 4. Classification of Dis-
eases involving the External Ear,
5. Microbiology, 6. Pathology of
External Otitis, 7. Animal Experi-
ments, 8. Chemistry, 9. Pathogene-
sis of Diffuse External Otitis and
Otomycosis, 10. Prophylaxis of Ex-
ternal Otitis, and 11. Treatment. As
an aid to further study, an exhaust-
ive reference list and bibliography
supplements each chapter.

External otitis, involving either

the auricle or external auditory ca-
nal, has never been a satisfactory
or easy condition to treat For many
years, external otitis was thought to
be caused by various fungus organ-
isms Now, largely due to Dr. Sen-
turia’s studies, it is known that vari-
ous gram-negative bacilli are the
chief offenders. As a result of these
studies, methods of treatment have
been clarified and made much more
effective.

In the author’s characteristic fash-
ion, the chapter on Treatment is
comprehensive and complete. For
each condition, specific directions
and prescriptions are given. Fortu-
nately, vague generalities are avoid-
ed. It is refreshing to see that the
author makes sure the new drugs
specified are listed according to the
proper pharmaceutical manufacturer.
It is interesting to note that old
tried and tested drugs ( Burow’s so-
lution and Cresatin) are still used,
supplemented by the new antibiotic
and cortisone mixtures.

All in all, this is a most interest-
ing and factual work. I believe it
is unique in that it is possiblv the
first all inclusive work concerning
diseases of the external ear. I per-
sonally feel grateful to Dr. Senturia
and his associates for this fine book.

Physicians, medical students, resi-
dents in otolaryngology, and oto-
laryngologists, who desire a conven-
ient reference to current data of
diseases of the external ear should
find this book very rewarding.

George M. Tangen, M.D.

•

Brain Mechanisms and Drug Action,
edited by William S. Fields,
M.D., 1957. Springfield, Illinois:
Charles C Thomas, 147 pages.
$4.25.

The provocative and encompassing
title suggests a multidiseiplined ap-
proach dealing with the basic mech-
anisms concerned with activity of
neurotropic drugs. Several disci-
plines are covered, including those
of nervous system electrophysiology,
neuroendocrinology, and psychology.
The broader aspects of neurophar-
macology are only lightly touched
upon, and the large body of neuro-
chemical information on drug activ-
ity is notably absent. The drugs are
also limited with the principal at-
tention devoted to the tranquilizing
agents chlorpromazine and reserpine.

This publication represents one
of a series of symposia sponsored by
the Houston Neurologic Society.

( Continued on page 43A )

In its Second Half-Century as in the First
the Abbott Hospital Medical Staff,
the Governing Board and the
Administration stand ready to serve.

Announcing the opening of expanded facilities for

general acute care in medicine, surgery

and the surgical specialties about August 1, 195S.

The Abhott Hospital

including Janney Children’s Pavilion

Minneapolis

40A

BOOK REVIEWS

( Continued from page 40A )

The book is organized in separate
papers dealing with the experimen-
tal results of a number of investi-
gators, utilizing prineipally the tran-
quilizing drugs. The opening paper
is a succinct and simplified review
of the reticular activating system by
R. Livingstone. This is the only ana-
tomicophysiologie system so select-
ed. The reason for the selection of
this system and deletion of others
concerned with drug action is not
apparent. The next paper is an elec-
troencephalographic study of the ef-
fects o( tranquilizers on the reticular
system of Himwich and Rinaldi.
Marrazi’s succeeding contribution
utilizes evoked potentials in the
study of the same drugs. E. K. and
F. F. Killen report on the use of
these agents employing paired shock
stimuli, evoked potentials, and elec-
troeneephalographie arousal thresh-
olds. The pituitary adrenal response
following toxic systemic stress ( di-
lute formalin subcutaneously) and
emotional stress ( forced restraint )
is covered bv R. Guillemin. The fi-
nal paper by J. V. Brady deals with
the effect of tranquilizers on condi-
tioned behavior. D. Mck. Rioch
aptly summarized the conference.

In general, the papers were
thoughtfully and clearly presented.
They provide additional information
on small foci of the problem of
brain mechanisms of drug action
but leave vast portions of the field
untouched.

Maynard M. Cohen, M.D.

•

The Medical Interview, by Ainsi.ie
Meares, M.B., B.S., B.Ag., 1957.
Springfield, Illinois: Charles C
Thomas. $2.50.

This is a big-little hook — big in the
sense that it offers valuable help in
the art of medicine and little in that
it comprises only 112 pages.

Psychiatrist Meares brings to our
attention a long neglected art in the
practice of medicine. It is simply
the establishment of a friendly rap-
port between the physician and the
patient which results in faith and
confidence in the physician.

With the many technical advances
in the field of medicine, less and less
attention has been centered on this
important relationship. The busy
doctor, surrounded by a mountain of
laboratory tests, finds little time to
visit with the sick patient.

Dr. Meares presents the interview
as an informal friendly exchange of

ideas between doctor and patient,
which relieves the emotional tension.

There are various steps involved
in the interview. Each step tends
to establish a closer understanding
and a better acceptance of the med-
ical examinations that are to follow.

The gentle and friendly exchange
of each other’s interests leaves the
patient with a feeling of receptivc-
ness to further medical procedures
and a confidence in the doctor.

In our contacts with patients, we
are frequently confronted by the
pause of silence which, unless un-
derstood, can lead to bad rapport.
Dr. Meares has this to say, “Silence
in the interview is much more than
the mere cessation of speech. It has
meaning. It has a cause and it pro-
duces effects both on the patient
and on the physician. Silence is
emotionally charged. On account of
this, it can be used to the great
benefit of the patient, but its inept
use can do great harm.” We are re-
minded of the old saying, “The best
substitute for wisdom is silence.”

All physicians should read this
book and benefit from it. The prac-
tice of its principles may not make
more money for the doctor, but he
will acquire more contented patients.

Arnold S. Anderson, M.D.

CLINICAL CONFERENCE
MISSISSIPPI VALLEY MEDICAL SOCIETY

(The Mid-West’s Greatest, Intensive Post-Graduate Medical Asscmhhj)

23rd ANNUAL MEETING

HOTEL MORRISON, CHICAGO, SEPT. 24-25-26, 1958

OVER 40 CLINICAL SPEAKERS

PROGRAM GEARED TO GENERAL PRACTITIONERS AND GENERAL SURGEONS
PANELS ON TIMELY TOPICS
BIG SCIENTIFIC AND TECHNICAL EXHIBIT HALL
MEETING and MEMBERSHIP OPEN TO ALL STATE SOCIETY MEMBERS
SOCIETY IS NON-PROFIT WITH NO PAID OFFICERS

Plan now to attend and make reservations at Hotel Morrison.

Write for preliminary program to

MISSISSIPPI VALLEY MEDICAL SOCIETY (Est. 1935)

Post-Graduate Medical Society of 111., Ia., Kan., Minn., Mo., Neb., N.D., S.D., Wis.
Harold Sxvanberg, M.D., Secretary, W.C.U. Bldg., Quincy, 111.

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VV I V w' W' V NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

The Tolbutamide Dilemma

E. A. HAUNZ, M.D.

Grand Forks, North Dakota

It has been pointed out that “the search for
oral antidiabetic agents is as old as our knowl-
edge of diabetes mellitus,”1 although the first
major breakthrough did not occur until 1955,
when carbutamide was made commercially avail-
able in Europe. Fortunately, in this country, the
use of carbutamide never passed the clinical re-
search stage, being superseded by the develop-
ment of tolbutamide, which is decidedly less
toxic but possessed of slightly less hypoglycemic
potential than carbutamide. The obvious efficacy
of tolbutamide in lowering blood glucose levels,
coupled with an apparent but not totally proved
innocuousness, has resulted in unprecedented
oral medication of nearly a quarter of a million
diabetic patients who have now abandoned in-
sulin.

While tolbutamide is not actually an insulin
substitute, its use is rapidly expanding despite
lack of conclusive evidence that it accelerates
peripheral glucose utilization and that it is, in
realitv, devoid of long-term toxic effects, cumu-
lative or otherwise. Apart from its obvious hypo-
glycemic effect, virtually, the sole fact conclu-
sively established is that tolbutamide and related
sulfonylurea compounds are ineffective in the
total absence of islet-cell function, in ketoacido-
sis, and in the control of juvenile diabetes.

e. a. haunz is associate professor of clinical medicine
at the University of North Dakota School of Medi-
cine, on the staff of the Grand Forks Clinic, and
past chairman of the Board of Governors of the
American Diabetes Association , Inc.

Criteria devised for the selection of likely can-
didates for tolbutamide therapy have not been
uniformly successful, because a significant num-
ber of patients prove to be “exceptions to the
rule.” Contrariwise, criteria for the prediction
of likely therapeutic failures are more easily
formulated and more reliable. As Levine suc-
cinctly puts it, “One thing that seems clear, how-
ever, is what the sulfonylureas do not do.”- With
strict adherence to and close scrutiny of such
criteria, patients may be spared a great deal of
grief and unnecessary expense. Under the pres-
sure of drug salesmen, the compelling forces of
the lay press, and, finally, the patient’s own de-
mands, it is not unexpected that physicians’
usual conservative barriers weaken and, perhaps,
too often yield to these influences.

If it were not for the fact that tolbutamide is
competing with an agent seasoned with a gen-
eration of therapeutic triumph and apparent
freedom from immediate or long-term toxic ef-
fects, there would be much less justifiable criti-
cism of what appears to be unwarranted enthu-
siasm to simply replace a daily injection with a
pill. In the July 8, 1957, issue of Life magazine,
Senator Clinton P. Anderson, himself a diabetic
for well over twenty years, criticized the “tone”
of a preceding Life article, titled “The Diabetic’s
Life-giving Ordeal,” in which Mr. Lee grimaces
with pain as he injects his insulin in the absence
of his wife, who “cannot bear to watch. The
senator states, “Tell the diabetics not to give
themselves too much sympathy for doing a mi-

nute segment of the daily task of getting spruced
up in the morning.

Conceding that a high percentage of diabetic
patients exhibit an impressive response to tol-
butamide, the wisdom of substituting this drug
for insulin simply for convenience may be logi-
cally challenged in view of our currently meager
factual knowledge. On the other hand, success-
ful transition from insulin to tolbutamide is un-
questionably a most rewarding experience in
cases of poor vision, parkinsonism, hemiplegia,
senility, and other incapacitating disorders which
render self-administration of insulin difficult or
impossible. It is for these patients that tolbuta-
mide may be heralded as a most notable event
in therapeutics. On the other hand, why not ask
ourselves a pertinent question: Are we really jus-
tified in rapidly converting such vast numbers
of diabetic patients, previously well controlled
on insulin, to a drug whose long-term effects are
enigmatic and whose precise pharmacodynamics
are so poorly understood? To fortify this ques-
tion, we must realize that this appears to be only
the beginning of a new era in therapeutics, for
newer oral antidiabetic compounds are already
under study, such as DBI and chlorpropamide,
which may be capable of accelerating peripheral
utilization of glucose.

It has been suggested that the “double blind”
method be utilized in future clinical studies of
milder diabetic patients who are converted from
relatively small doses of insulin to tolbutamide
therapy. Such an approach would expose many
cases in patients who, whether overweight or not,
appear to be better controlled simply because of
stricter adherence to dietary measures. Further-
more, a number of such patients could thus be
exposed who would require neither insulin nor
tolbutamide to control their diabetes. This is an
obvious example of improper use of either drug.

The practitioner must be keenly alerted to
the fact that stress situations, such as infection,
surgery, trauma, shock, and pregnancy, not un-
commonly exacerbate the diabetic state and that
the risk of ketoacidosis and/or coma in such
patients is very pronounced. The need to resume
insulin may be emergent. The physician must
create awareness of this fact in the patient.

The concept of dosage of tolbutamide is now
quite clearly established. The effective dose is
usually 1 gm. daily and not more than 2 gm. per
day. Administration of 3 to 5 gm. or more per
day not only fails to exert any further hvpogly-
cemic effect but, in some cases, increases livper-
glycemia and glycosuria for unknown reasons.
Insulin should never be withdrawn abruptly.

The statement that tolbutamide is overtlv less

toxic than carbutamide should not imply that we
can ignore these effects from the former drug.
Dermatitis, nausea, gastric irritability, headache,
and leukopenia still occur in approximately 3 per
cent of cases. Liver function is sometimes tem-
porarily disturbed, as reflected in transient ab-
normal bromsulphalein tests and alkaline phos-
phatase determinations. Except for allergic phe-
nomena, insulin has appeared to be singularly
innocuous for thirty-five years. Will tolbutamide
or related compounds meet this challenge? It
is not known as yet whether the supposed beta-
cvtotropic effect of tolbutamide may in time
eventuate in beta-cell exhaustion.

A curious phenomenon which merits further
study is the apparent difficulty occasionally en-
countered in attempting to re-establish insulin
therapy after tolbutamide failures. Sheridan’5
has encountered 2 and the writer 3 patients ex-
hibiting this phenomenon. One of the latter pa-
tients, a 47-year-old male, lapsed back into pro-
found ketoacidosis after two weeks of extreme
difficulty in re-establishing control on insulin.
This patient, previously quite stable for several
years on insulin, became very unstable or “brit-
tle” for a period of several weeks thereafter.
During his bouts of ketoacidosis, extreme tachy-
cardia was noted without shock. He died of an
acute coronary occlusion three months later.
Autopsy confirmed the diagnosis, and there was
no evidence of myocarditis, such as is seen from
carbutamide therapy.

An unbiased appraisal of tolbutamide should
include the statement that a significant number
of so-called “stable” diabetic patients exhibit
even smoother control of the blood sugar on tol-
butamide than on insulin therapy. However,
this should be weighed against the observation
that, if the patients are restricted to those who
must have oral drug therapy and respond well to
tolbutamide, approximately one-third will even-
tually have to resume insulin. The latter group
are termed “secondary failures,” and a few of
these patients exhibit somewhat higher insulin
requirements than previously.

The economics of tolbutamide versus insulin
administration merit some comment. Since the
oral medication is customarily indicated only in
adults with maturity-onset diabetes who require
less than 40 units of insulin daily, the cost of
insulin for such patients never exceeds $4.38 per
month and is on the average considerably lower.
Receiving tolbutamide, the current rate of which
is approximately $15.00 per 100 tablets (Is gm.
each), the patient usually requires a minimum
of 1 to 3 tablets a day, costing from $4.50 to
$13.95 a month. In my experience, a number of

288

THE JOURNAL-LANCET

patients have taken only 20 units of insulin daily,
and they are quite disturbed to find that, if they
require 2 tolbutamide tablets daily for adequate
eontrol, their monthly cost for medication jumps
from about $2.20 to $9.00 a month. Relatively
few patients are satisfactorily controlled on 1
tablet a day.

Finally, it seems only fair that the patient
should have a voice in the decision to change
from insulin to tolbutamide. I have been amazed
at the percentage of my patients who prefer to
“stick with insulin” when they are presented with
an honest forthright picture of our present
knowedge of the action of tolbutamide in lay
language. Even patients who come in requesting
a trial of “the pills” not infrequently reverse their
decisions. Among 72 patients who either request-
ed or were offered a trial of tolbutamide, 52
(72.2 per cent) either withdrew their request
or refused the drug. No attempt was made to
“pressure” the patient in either direction, the
approach being very similar to that advised by
Duncan4 who states, “The patient is made aware
that we are traveling an uncharted course and
must be more alert than ever until the potentials,
good or bad, of these drugs, as they affect the
great variety of patients under a great variety
of circumstances, are familiar to us.”

In an effort to establish a broader base for the
views expressed here, the accompanying brief
questionnaire was sent to eminent clinicians and
investigators in Boston, New York, Philadelphia,
Cleveland, Detroit, Chicago, St. Louis, Denver,
San Francisco, and Seattle. The opposing an-
swers to question number 5, evenly divided, are
enough in themselves to justify the word “dilem-
ma” in the title of this article. This is admittedly
a small sampling of clinicians’ opinions, but the
latter are bona fide specialists in diabetes and
as a group are seeing several thousand diabetic
patients. A separate inquiry revealed that the
number of patients who had been converted
from insulin to tolbutamide therapy among the
physicians queried ranged from 1 to 20 per cent.

It is perhaps disheartening but not unexpected
that physicians eminently qualified in the spe-
cialty of diabetes do not share identical opinions
with regard to the questions asked. This simply
strengthens the view that incontrovertible evi-
dence for a clear-cut position for tolbutamide in
our therapeutic armamentarium is sorely lacking
at present. Much of the current literature is
based on rather tenuous hypothetical concepts.

The wheels of medical progress must ever con-
tinue in a forward direction, but their velocity
ought to be tempered by the soundness and
safety of investigative inroads which should lead

QUESTIONNAIRE

1. Do yon feel that tolbutamide is being used
too extensively and too indiscriminately by gen-
eral physicians in your area?

Yes 6

No 3

Don’t know 1

2. Have you encountered diabetic patients pre-
viously satisfactorily controlled on insulin who
developed ketoacidosis on tolbutamide and had
to be re-established on insulin?

Yes 8

No 2

3. Have you seen any actual deaths from dia-

betic coma developing after tolbutamide tlier-
apy?

No 10

4. Do you think practitioners in general often
fail to heed established criteria for selection of
diabetics for trial with tolbutamide?

Yes 7

No .... 2

Don’t know 1

5. Do you believe tolbutamide is now an estab-
lished and acceptable treatment in properly se-
lected diabetics?

Yes 3

No 5

6. Have you sometimes found it very difficult
to re-establish insulin treatment in so-called
tolbutamide failures?

Yes 2

No 8

to a common destination — a safe haven in which
the patient not only escapes the ravages of dis-
ease but likewise the penalties of therapeutic
zealots who often try too much too soon.

In conclusion, the preceding commentarv is
by no means designed to nurture a nihilistic ap-
proach to the use of tolbutamide, for many of us
recall the early skepticism which accompanied
the advent of insulin. Rather, it is hoped that
these remarks represent a modest attempt to
season unwarranted enthusiasm with enough
conservatism to safeguard the well-being of the
diabetic patient.

REFERENCES

1. Goldner, Martin G.: Historical review of oral substitutes

for insulin. Diabetes 6:259, 1957.

2. Colwell, A. R., Sr., Dolger, H., Levine, R., Duncan, G.

G., and Root, M. A.: Oral hypoglycemic agents, panel dis-

cussion. Diabetes 7:53, 1958.

3. Sheridan, E. P.: Personal communication.

4. Duncan, G. G.: What the patient should be told about oral

hypoglycemic compounds, editorial. Diabetes 6:534, 1957.

JULY 1958

289

The Modern Treatment of
Compound Fractures

GEORGE W. HORTON, M.D.
Odessa, Texas

64 A compound fracture,” states Dr. Edward
L. Compere,1 “constitutes one of the most
serious of all emergencies; the involved bone is
exposed through the skin and must be consid-
ered to be potentially infected. The need for
prompt and adequate surgical care is as urgent
as that for the treatment of acute appendicitis,
a ruptured spleen or the perforation of a peptic
ulcer. Believing this to be true, and having
found very little about this subject in the litera-
ture since the period following World War II,
this paper is presented in the hope that interest
in this very serious problem will be stimulated
and that even greater improvements will be
brought about.

The most important aim is the attempt to pre-
vent infection. With a clean, healthy wound,
orthopedic surgery can give satisfactory results,
but the presence of infection presents an un-
usually difficult situation.

INITIAL TREATMENT

The wound should receive attention immediate-
ly, at least to the extent of being covered by a
sterile dressing in the emergency room. As soon
as the condition permits, the patient should be
carried to the operating room and a general an-
esthetic should be administered to allow for the
necessary exploration of the wound and also to
allow fixation of the fracture. Parasympathetic
blocks should sometimes be used to relieve vaso-
spasm before deciding to operate. Even the
smallest puncture wound should be excised.

The radical excision of dead and devitalized
tissues as an immediate procedure gained some
favor toward the close of World War I but really
came into importance during World War II.
Authors such as Stimson,2 Davis,3 Hampton,4
Peltier,5 Eaton,5 and others, including Key and
Conwell,7 have stressed the importance of atten-
tion to the wound.

george w. horton is (ii i orthopedist with offices in
Odessa, Texas.

Paper read before American Fracture Association
annual meeting in El Paso, Texas, October 1957.

OPERATIVE TECHNIC

The skin is shaved as close as possible to the
wound edge in such a manner that no hair is
allowed to drop into the wound to cause further
contamination. It is most important that the sur-
geon himself prepare the wound for surgery un-
less he is fortunate enough to have a well-trained
team of assistants. The doctor, after scrubbing
and putting on sterile gloves, covers the inside
of the wound with sterile gauze. Holding the
gauze in place with one hand, he then thorough-
ly scrubs the skin over an adequate area with
pHisoHex or one of its equivalents. Care should
be taken that no drops of water and soap carry
dirt from the outside of the patient’s skin down
into the wound. The sterile gauze from the
wound is then removed, and the wound edges
are more completely scrubbed, still taking care
not to contaminate the wound with any of the
solution of soapy water.

In more than 35 patients, I have had 1 fail-
ure and 2 serious infections. The failure resulted
when another surgeon convinced me that we
should try washing the wound out with pHiso-
Hex without protecting it with a sterile gauze;
in the other 2 cases, others had prepared the
wound. Many of these have been severe soft-
tissue wounds.

After the wound has been cleaned, the skin
edges are draped and excised. Any questionable
appearing skin should be excised also. Davis3
stated that, in his opinion, failure was more often
due to attempts to save questionable skin than to
any other factor. Particles of clothing or pieces
of gravel, metal, and so on, which may cause
pross contamination, should be removed with
forceps, if possible, and the wound should then
be thoroughly irrigated from the depths upward
with large amounts of sterile solution, such as
physiologic saline. At this time, it is advisable
to change gloves and instruments and to use
fresh drapes about the wound. Anv portions of
devitalized muscle should be completely excised
because infection is most likelv to occur in a
wound containing dead or devitalized tissue.

290

THE JOURNAL-LANCET

Before closure, if a tourniquet is used, it should
he removed and any tissue which does not
bleed adequately or show the proper color
should be excised to insure adequate removal
of this tissue. Important vessels, nerves, tendons,
and so on should be protected as much as pos-
sible.

The bone should then receive attention. Very
small pieces which are lying loose should be
removed and discarded. Large pieces which
are attached and not too grossly contaminated
should be thoroughly cleaned with a rongeur
or curet and irrigated with saline. Cultures
should be taken for sensitivity studies. At this
stage, any fixation which is to be carried out
should be done, and a decision should be made
as to whether to close the wound as a primary
procedure or to pack it open loosely. If there
is not an excess of gross contamination and if
the wound is being treated within the first six
to eight hours, I believe that the wound should
be closed. In closing, no overhanging tissues
should be left. The muscles should be approxi-
mated very loosely with running sutures of plain
catgut. Torn nerves and vessels should be su-
tured if feasible. By all means, the bone should
be covered with as much healthy tissue as pos-
sible, just as in a compound wound of a joint,
the synovium is closed, even though the re-
mainder of the wound is packed open. Lack
of covering tissue probably explains why more
tibias become infected.

The skin should be closed without tension.
In some cases, the skin will have become so
questionable or so much swelling will have oc-
curred that this cannot be done without the aid
of relaxing incisions, which can be made at some
distance on each side of the wound or with the
use of a sliding flap. In some cases, of course,
full thickness skin grafts need to be applied.

If the condition of the patient is such that
immediate attention cannot be given to the
wound, it should be treated as soon as possible.
Stimson,2 in reporting on the handling of com-
pound fracture wounds in the Italian campaign,
stated that they had obtained excellent success
by closing wounds after several days in transit.

For wounds in which it is felt inadvisable to
do a primary closure or in which there is inade-
quate skin, preparation for a secondary closure
can be made. This consists of packing the wound
rather loosely with fine mesh gauze, which
drains more freely than a tight packing of vase-
line gauze. The findings of World War II have
amplv established the procedure of secondary
closure, which can be carried out from five to
ten days later.

In spite of all of the literature on war experi-
ences, many medical men are still reluctant to
close the wound of a compound fracture. Davis3
presented a very good argument for a primary
closure by reporting his series of 150 cases in
which 87 per cent of the wounds healed by first
intention. Fifty-six of these cases were tibias,
which, in most instances, were protruding and
soiled, and the majority of cases healed as
would a simple fracture. Against this, he pointed
out some of the penalties of the open treatment
with sequestration and so forth and a much
longer convalescence.

One other important point is that strict asep-
sis should be carried out, just as though no anti-
biotics or antisera of any sort were available.
No matter how helpful antibiotics are, they
should not be completely relied upon. Peltier5
stated this very clearly when he said, “Antibiotics
and antisera cannot overcome deficiencies of in-
adequate surgical techniques, although they are
of great value in preventing or localizing infec-
tion.”

Eveleth8 reported on the use of sulfonamides
in compound fractures in the days before peni-
cillin. He found that 19.3 per cent of cases be-
came infected without and 19 per cent with the
drug and came to the conclusion that it had no
particular value in the treatment of the com-
pound wound.

Peltier3 summed this up succinctly when he
stated that one should not rely on “a broadside
of fungal derivatives, but on an adequate sur-
gical excision of the wound.”

If infection does occur, cultures should be ob-
tained from aspiration or wide opening of the
wound and sensitivity studies used so that
proper antibiotics can be administered. It is
known, of course, that these sensitivity studies
are not 100 per cent correct in all cases, but
they offer a very good guide. Probably the two
most useful antibiotics are penicillin and strep-
tomycin in combination as a prophylactic used
immediately following surgery until the wound
is healed or until culture can be obtained to
show the need for some other antibiotic.

INTERNAL FIXATION

We come now to the question of fixation of the
fractured bone. In the Spanish Civil War, Tru-
eta felt that immobilization and infrequent dress-
ing were extremely important in the prevention
of infection.

While it is felt now that a primary suture is
an improvement over the Trueta-Orr method,
the principle of immobilization as a means of
preventing infection is still very important.

JULY 1958

291

Fig. 1. Case 2. Note extensive scarring caused by the
accidental compound wounds.

Fig. 2. Case 3. Trochanteric and subtrochanteric frac-
ture. Note extent of compound wound of soft tissue.

Fig. 3. Case 3. Note extent of deep infection as shown Fig. 4. Case 3. Photograph of x-ray not very clear but
by opaque media (Diodrast) injected into sinus. bone well healed, even in saucerized area. Wounds have

been healed for four and one-half years.

Fig. 5. Case 6. Note extensive soft tissue damage and
severe comminution of tibia.

Fig. 6. Case 6. Fracture healing, fixation b\ pins incor-
porated in cast.

292

THE JOURNAL-LANCET

Therefore, it is felt that just as immobilization
of a fracture decreases shock it also favors the
healing of the wound without infection.

There are still discussions going on as to
whether or not internal fixation should be carried
out in the presence of a compound wound.
Davis1 2 3 4 and Peltier5 both advise metallic fixation
when indicated for the bone, even in the pres-
ence of a compound wound. Key and Conwell7
state, “While it is true that in some cases of
internal fixation mild infection will appear and
will have to be treated, and the internal fixation
removed, there is no reason to not use metallic
devices.”

There are very good arguments for the use of
a primary closure as opposed to open treatment
and watchful waiting. So many cases of internal
fixation have now been used in which the frac-
ture was converted to a simple fracture, conva-
lescent time and disability were saved, and the
need of future operations eliminated that closure
and fixation are advisable. More than 90 per cent
healed by first intention and progressed as a
simple fracture. The cases given are only the
poor ones. We would use different methods in
some, but hindsight is better than foresight.

As can be seen in a few of the cases presented
here, the infection was so mild that the bone
could be allowed to heal before removal of the
internal fixation, at which time a mild drainage
completely disappeared. After three years, no
further trouble was experienced by the patients.

CASE HISTORIES

Case 1. A. J. S., age 28, an oil field worker, sustained
bilateral compound fractures of his lower legs in January
1955. An intramedullary nail was inserted in the left
leg with primary closure. This wound healed as a sim-
ple fracture. The right leg was operated upon next. The
wound was prepared by another doctor, and an Eggers
plate was used with primary closure. Infection became
evident after several months. The plate was removed,
and the wound was debrided and closed except for a
penicillin catheter. It healed with a moderate valgus.
The patient has been working for sixteen months.

Case 2. A. M. L., age 26, fell 50 ft. from a rig in
September 1956. He suffered compound comminuted

fractures of the right femur and left tibia and fibula.
An intramedullary nail was inserted in the right femur
with primary closure. The injury healed as a simple
fracture. After this operation, a plate, screws, and pri-
mary closure with relaxing incisions were used in the
left leg. The patient was working within seven months.
Infection appeared in the right tibia. The plate was re-
moved, and grafting will probably be necessary (fig-
ure 1 ).

Case 3. H. R., age 32, was in an accident May 1953
that resulted in an open wound resembling a Smith-
Petersen incision. Primary closure was performed after
insertion of an intramedullary nail. The skin healed by
first intention but had a deep abscess requiring incision
and drainage. Opaque media was then injected, scar
tissue excised, and the bone curetted. Except for a very
small sinus and occasional drainage, the wound healed.
Seven months later, the nail was removed and drainage
ceased. After four years, hip motion was somewhat lim-
ited but caused no trouble (figure 2, 3, and 4).

Case 4. G. W. C., age 32, suffered a severe, com-
pound, comminuted fracture of the right tibia in No-
vember 1955. After insertion of an intramedullary nail
and screw, primary closure was carried out with relax-
ing incisions. Wounds and bone healed. The patient was
working in eight months and was well after two years.

Case 5. G. O’N., age 30, was injured in an oil rig acci-
dent in December 1953. When seen, the tibia was pro-
truding and dirty underclothes covered the bone. Within
five hours, an intramedullary nail had been inserted with
primary closure. Two months later, low grade infection
developed. Cultures were resistant to all antibiotics, but
sulfonamides provided some control. The bone healed,
and the nail was removed. Saucerization and skin graft
were performed. Infection destroyed the union after six-
teen months. A guillotine amputation was necessary.
This case was a failure.

Case 6. J. A. H., age 45, an oil field worker, crushed
his left leg in May 1956. His wounds were very severe
with a comminuted compound fracture of the tibia. Pri-
mary closure was performed with traction on a Braun
frame. When last seen after six weeks, the wounds had
healed. Steinmann’s pins were removed from both ends
of the long leg cast, and the bone was found to be
fairly stable (figures 5 and 6).

CONCLUSIONS

In my opinion, modern treatment of compound
fractures should consist of proper preparation
of the wound, adequate excision of devitalized
tissue, primary closure of the wound with in-
ternal fixation when indicated, and proper use
of antibiotics.

REFERENCES

1. Compere, E. L.: Treatment of compound fractures. Wis-

consin MJ. 43:320, 1944.

2. Stimson, B. B.: Treatment of compound fractures in Italian
campaign. Ann. Surg. 124:435, 1946.

3. Davis, A. G.: Primary closure of compound-fracture wounds:
with immediate internal fixation, immediate skin graft, and
compression dressings. J. Bone & Joint Surg. 30-A:405, 1948.

4. Hampton, O. P., Jr.: Management of compound fractures

in their early phases. Surg., Gynec. & Ohst. 84:772, 1947.

5. Peltier, L. F.: Treatment of open (compound) fractures.

GP 10:34, 1954.

6. Eaton, G. O.: Overseas treatment of compound fractures

of long bones. J. Bone & Joint Surg. 28:434, 1946.

7. Key, J. A., and Conwell, H. E.: Fractures, Dislocations

and Sprains. Sixth Edition, St. Louis: Mosby, 1956, p. 160.

8. Eveleth, M. S.: Use of sulfonamides in compound frac-

tures. J. Bone & Joint Surg. 27:486, 1945.

JULY 1958

293

Obstetric Emergencies in General Practice

DENIS CAVANAGH, M.D.

Miami, Florida

In the United States today, about 85 per cent
ot deliveries are carried out by general prac-
titioners, so the bulk of responsibility for mater-
nal care lies on their shoulders. The importance
of adequate prenatal care in reducing the num-
ber of obstetric emergencies seen in general
practice cannot be overemphasized. In many
cases, danger can be anticipated so that the
astute practitioner may avert disaster or, at least,
be prepared for complications when they arise.
A carefully recorded general and obstetric his-
tory is no less important than the examination.
Special attention to the weight of previous child-
ren and the correlation with present pelvic and
fetal estimation often leads to anticipation of
intrapartum dystocia. If a history of previous
postpartum hemorrhage is obtained in a grand
multipara with chronic anemia who is expecting
twins, the possibility of further postpartum hem-
orrhage is obviously great. In a patient with a
blood pressure in excess of 150/100 mm.Hg at
her first prenatal visit or who reveals a history of
hypertension from any cause in a previous preg-
nancy, the likelihood of losing her and her child
in this pregnancy is increased, and the physician
must be forever cognizant of the increased dang-
ers, particularly from eclampsia and abruptio
placentae.

Ideally, patients should be seen at least every
four weeks up to the twenty-eighth week; from
the twenty-eighth to the thirty-sixth week, every
two weeks; and every week for the last month of
pregnancy. Pelvic examinations should be per-
formed at the sixteenth week for purposes of
diagnosis, pelvic assessment, exclusion of ovarian
cysts, and so forth and again during the thirty-
sixth week for final assessment in regard to possi-
ble cephalopelvic disproportion. The patient
should have an initial hematocrit, and her blood
group, including llh, should be known by her
doctor. Every patient should be given a booklet

denis cavanagh is instructor in the Department of
Obstetrics and Gynecology at the University of
Miami School of Medicine at Jackson Memorial
Hospital.

Paper presented at the fourth Bahamas Medical
Conference, December 13, 1957.

of general prenatal instructions. Diet, mineral,
and vitamin supplements should be prescribed
as required. Specialist advice should be sought
as indicated and ancillary technics, such as x-ray
pelvimetry and placentography, utilized where
necessary.

When a potentially dangerous case is en-
countered during the prenatal period and where
adequate facilities are not available, the patient
should be referred to the nearest maternity
center. Any practitioner who is so isolated that
he has no specialist help at hand for emergencies
should be sure that he has at his disposal mor-
phine sulphate, magnesium sulphate, sterile man-
ual removal gloves, a pair of obstetric forceps
with which he is familiar, and facilities for trans-
fusion of a plasma substitute or, preferably,
whole blood. In cases of severe hemorrhage, at-
tention must be directed to staunching the How
with early and adequate replacement of blood
loss.

“There are but two things that have much
effect on me at labor— hemorrhage and convul-
sions.” This statement, made by William Hunter
two hundred years ago, is still largely applicable
to obstetric emergencies today. Dewhurst’s1 re-
view of 489 such emergencies in the Manchester
area of England from 1947 to 1950 makes this
amply clear (table 1).

HEMORRHAGE DURING PREGNANCY

Hemorrhage may occur from the decidua dur-
ing pregnancy or from an associated lesion, such
as a cervical erosion or polypus. Furthermore,

TABLE 1

NUMBERS AND TYPES OF CASES TREATED

Type

Number

Retained placenta

245

Postpartum hemorrhage and shock

143

Abortion

33

Eclampsia

23

Antepartum hemorrhage

9

Secondary postpartum hemorrhage

9

Other conditions

27

Total

489

294

THE JOURNAL-LANCET

Fig. 1 . Aspiration of non-
clotted blood from cul-de-
sac of Douglas with syringe
and needle confirms diagno-
sis of intraperitoneal hemor-
rhage. (Diagram from
Chews, R. L.: Culdocente-
sis at the Jackson Memorial
Hospital — 400 cases. Am.
J. Obst. & Gvnec. 75:914,
1958).

considerable bleeding may occur from vulvar or
vaginal varicosities. As a general rule, none of
these cause serious bleeding and the flow is
readily controlled.

Abortion is the commonest emergency in early
pregnancy, and 10 per cent of all pregnancies
terminate in this way. This was the recorded
cause of death in 266 women in the United States
in 1955. Most bleeding occurs witli the incom-
plete and criminal types, the latter tvpe charac-
terized by pyrexia and parametrial tenderness.
Pelvic examination should be carried out as asep-
ticallv as possible. When bleeding is heavy, the
cervical canal is usually dilated with the con-
ception products present in the vagina or pro-
truding through the internal os, but, in any case,
as soon as incomplete or inevitable abortion is
diagnosed, the uterus should be emptied without
delay. Often, the products can be evacuated digi-
tally or with the help of ring-type sponge forceps.
In general practice, such cases may be adequate-
ly managed by giving 5 units (M cc. ) of Pitoein
intramuscularly with 1/6 gr. of morphine sulfate
and repeating the Pitoein in one-half hour. Some
prefer to use 1/320 gr. of Ergotrate intravenously
or intramuscularly in place of the Pitoein. I feel
that Pitoein is more physiologic and that Ergot-
rate should be withheld until the conception pro-
ducts have been expelled and examined by the
attending physician. When satisfied that abortion
is complete, Ergotrate is then given parenterally.
As a rule, we prescribe 0.2 mg. of Methergine
orally every four hours for 6 doses to keep the
uterus retracted. Occasionally, medical methods
fail, and, in these cases, the patient should be

transferred to a hospital for surgical completion
of the abortion. Furthermore, any patient who
does not respond to antishock therapy should be
transferred to a hospital immediately. Any pa-
tient who has had criminal interference should
be given antibiotics and tetanus antitoxin and
transferred to a hospital as soon as possible. In
the last two groups of patients, lower nephron
nephrosis is not uncommon, and these women
should be watched carefully for the development
of oliguria.

Ectopic pregnancy must be considered, es-
pecially the ruptured tubal variety. The symptom
complex of 6 to 8 weeks’ amenorrhea with vague
colicky lower abdominal pains preceding by per-
haps several days the onset of severe lower ab-
dominal pain, sometimes with a shoulder tip
element and associated with anemia and faint-
ness, is well known. On physical examination,
the finding of lower abdominal rebound tender-
ness in conjunction with a tender adnexal mass
in a pallid, shocked patient strongly suggests the
diagnosis. In early cases, the aspiration of non-
elotted blood from the cul-de-sac of Douglas con-
firms the diagnosis. A syringe with a No. 16
spinal needle attached is all the equipment that
is required. Anesthesia is unnecessary, although
25 to 50 mg. of Demerol may be given intraven-
ously. Ruptured tubal pregnancy occurs about
20,000 times annually in the United States,2 and
151 women died from this cause in 1955/ Many
of these would have been saved if this simple
test had been more widely used ( figure 1 ) .

The patient should be treated for shock, if
present, and transferred to a hospital for laparo-

JULY 1958

295

tomy immediately after the diagnosis has been
established.

Ulceration of the vagina should be borne in
mind, particularly after attempts at criminal
abortion by the insertion of potassium perman-
ganate crystals. At Jackson Memorial Hospital,
we see about 15 to 20 such cases annually; a few
of these patients are in shock from heavy bleed-
ing. This may occur if the patient uses a solution
in which the crystals have not been allowed ten
minutes to dissolve. A warm saline douche is
given to remove residual crystals. A vaginal pack
usually controls hemorrhage, but sometimes
hemostatic sutures are required.

Carcinoma of the cervix occurs, according to
Kistner,4 in about 1 in 2,000 pregnancies. Al-
though rare, this is an occasional cause of severe
hemorrhage. Speculum examination will reveal
the cause, and cauterization with acetone in
addition to a vaginal pack will control the How
until the patient reaches the hospital.

Antepartum hemorrhage in the last trimester
should always be regarded seriously, and, even
it bleeding is slight, patients are best transferred
immediately to a hospital for full investigation.
No vaginal or rectal examination should be per-
formed, and even gentle speculum examination
is better deferred until placenta previa has been
excluded. When bleeding is severe, immediate
blood replacement is required, and, if the facili-
ties are available, transfusion should be started
before or during transportation to the hospital.
Painless bleeding in a multiparous patient with
an abnormal presentation and high presenting
part suggests placenta previa. On the other hand,
abdominal pain with vaginal bleeding and a hy-
pertonic and tender uterus in a preeclamptic
primigravkla is more suggestive of abruptio
placentae. In a patient who has had a previous
cesarean section, the possibility of a ruptured
uterus must be borne in mind. Occasionally, va-
ginal and cervical lesions cause heavy bleeding as
may rupture of the marginal sinus of the placenta
or vasa previa. Generally, the specific diagnosis
is not made until the hospital is reached, and,
indeed, in about 30 per cent of patients, the
cause remains undetermined.

Table 2, prepared by Ferguson/' presents an
analysis of 97 cases of antepartum hemorrhage
among 2,251 deliveries.

In a dire emergency, when the cervix is only
about 3 to 4 cm. dilated in the presence of pla-
centa previa with the patient bleeding heavily,
it may be possible to effect adequate tamponade
by using the dead child in conjunction with scalp
(Willett forceps) or leg traction. Vaginal pack-
ing increases the danger of infection and is of

THE JOURNAL-LANCET

little value in controlling hemorrhage. In these
cases, all efforts should be directed toward
blood replacement and delivery.

Ideally, only fully equipped hospitals with
adequate resident staffs, including anesthesiolo-
gists and pediatricians, should accept cases of
antepartum hemorrhage. The patient should be
typed and matched for 1,000 cc. of blood upon
admission. Immediate treatment depends upon
the amount and persistence of bleeding. If bleed-
ing stops, further treatment depends upon the
location of the placenta and the maturity of the
pregnancy. If diagnosis is in doubt, the patient
is treated as a case of placenta previa.

Placenta previa. If bleeding stops, the patient
should be kept under observation in the hospital
until the fetus is about 2,500 gm. Speculum and
vaginal examination should then be performed
in an operating room with the patient prepared
for immediate cesarean section, lest a central or
partial placenta previa be found. Often, a patient
with an anterior marginal placenta previa can be
delivered vaginally following rupture of the
membranes and dilute Pitoein infusion. When
the placenta lies posteriorly and overlaps the
sacrum, the true conjugate is more likely to be
reduced, and cesarean section is often necessary.
Soft tissue x-rays may reveal the placenta in the
upper uterine segment, so that the vaginal ex-
amination need not he postponed even if the
baby is small.

If bleeding continues or recurs and placenta
previa is suspected, an aseptic vaginal examina-
tion should be performed in the operating room
with the staff alerted for possible immediate
cesarean section. This conservative approach, as
advocated independently by Johnson6 and Maca-
fee7 in 1945, together with the increased use of
the abdominal route for the delivery of patients
with placenta previa, has done much to reduce
the maternal and fetal mortality.

Abruptio placentae usually presents a charac-
teristic picture. Typically, it occurs in the pre-

TABLE 2

CAUSES OF HEMORRHAGE IN 2.251 DELIVERIES
FIRST AND THIRD QUARTERS OF 1954

Diagnosis

No. of cases

Rupture of marginal sinus

33

Cause undetermined

30

Abruption

13

Cervicitis

10

Placenta previa

6

Low-lying placenta

4

Circumvallata placenta

1

Total

97

296

eclamptic patient and the bleeding is associated
with abdominal pain of fairly sudden onset. The
uterus is hypertonic and tender in proportion to
the degree of concealed hemorrhage. In the
severe case, an increase in the size of the organ
is noted.

All patients with suspected abruptio placentae
should be taken to the hospital if possible. Then:

1. Immediate preparations should be made for
transfusion.

2. The uterus should be emptied as soon as
possible. Sometimes cesarean section may be re-
quired, but often artifical rupture of the mem-
branes and Pitocin infusion result in delivery in
a short time. Prompt delivery reduces the possi-
bility of hvpofibrinogenemia and of renal glome-
rular and tubular damage.

3. In all cases, the clotting time and clot re-
traction should be observed. Ideally, hematocrit
and fibrinogen estimations should be obtained.
Where the latter is not available, the simple
Fibrindex test is useful. Hvpofibrinogenemia
must be treated vigorously, and no surgical pro-
cedure should be started until this process has
been checked. At least 4 to 6 gm. of Fibrinogen
should be available as should blood, preferably
fresh. Platelets and the AC globulin factor are
useful but rarely available.

4. Hematocrit, blood fibrinogen, and electro-
lyte values should be carefully watched as well
as renal function. At the first sign of oliguria, a
protein deficient diet of the Borst's or Bull1’ tvpe
should be started.

5. If a Couvelaire uterus is found during cesar-
ean section, some authors feel that hysterectomy
is best performed because severe postpartum
hemorrhage is common. Generally, however, pro-
phylactic hysterectomy is unnecessary unless the
uterus continues to bleed after evacuation and
despite oxytocic therapy.

Rupture of the uterus occurs in about 1 of
4,000 deliveries. It is suggested by shock with
sudden onset of “tearing” abdominal pain in a
patient who has had a previous cesarean section.
It is often associated with the careless use of
Pitocin and may also occur as a result of an im-
pacted shoulder presentation or traumatic at-
tempts at internal version. Usually, the condition
occurs during labor, and the constant pain is
associated with the cessation of contractions.
Abdominal tenderness and rigidity are more
prominent with rupture of the upper segment.
Vaginal bleeding is more frequently encountered
in lower segment rupture. After the treatment of
shock, immediate transfer to a hospital for repair
of the uterus or, more probably, hysterectomy is
imperative.

Vasa previa rarely endangers the life of the
mother, but the fetal mortality is high. The diag-
nosis may be made before delivery if normo-
blasts are found in the stained vaginal blood
smear. Usually, however, the diagnosis is only
made after examination of the placenta, since the
condition is most frequently found in association
with a velamentous insertion of the cord.

Rupture of the marginal sinus rarely causes
severe obstetric hemorrhage and is often diag-
nosed as abruptio placentae, although none of
the stigmata of this much more serious condition
is present except vaginal bleeding. The diagnosis
can only be made after examination of the pla-
centa.

PREECLAMPSIA AND ECLAMPSIA

In 1954, 2,105 women died as result of childbirth
in the United States.1" Maternal killers in order
of importance were: toxemia, sepsis, hemorrhage,
heart disease, anesthesia, and malignancy. Des-
pite the fact that toxemia of pregnancy heads the
list, it is largely a preventable disease. On a basis
of improved prenatal care, Hamlin11 reported a
reduction in the incidence of preeclampsia in
Sydney from 10 per cent in 1946 to 1.8 per cent
in 1951, and the frequency of eclampsia was at
the same time reduced to about 1 in 7,000 preg-
nancies. The keystones in the prophylaxis of pre-
eclampsia are simply dietary restriction to avoid
excessive weight gain and bed rest for even the
mild case.

While few could fail to appreciate the urgency
of an eclamptic convulsion, the care of the pre-
eclamptic patient often leaves much to be de-
sired. While about 5 to 10 per cent of eclamptic
cases are fulminant, most cases could be prevent-
ed by simple measures, such as a diet low in
carbohydrate and sodium with the prescription
of diuretics, sedation, Serpasil, and bed rest.
When a patient shows a weight gain of more than
2 lb. per week or a blood pressure in excess of
140/90 mm. Hg with edema and albuminuria,
hospitalization should be arranged if at all possi-
ble. The same arrangements should be made for
patients with essential hypertension or chronic
nephritis who show the slightest increase in
edema or albuminuria.

Eclampsia is defined by the American Com-
mittee on Maternal Welfare as “the occurrence
of convulsions and/or coma in a pregnant or
puerperal woman when associated with hyper-
tension, edema, or albuminuria.” In about 90
per cent of cases, the development of eclampsia
is heralded by severe frontal or occipital head-
ache, visual disturbances, epigastric pain, and
vomiting. The onset of oliguria in association

JULY 1958

297

with the above is especially ominous. Hyper-
tension, albuminuria, and edema are almost in-
variably present, although in fulminating cases
the absence of the latter is a bad prognostic sign.
The importance of intensive therapy in severe
preeclampsia cannot be stressed too much, for,
as soon as a pregnant patient has an eclamptic
seizure, the danger to herself and her baby is
enormously increased. All cases of severe pre-
eclampsia and eclampsia are best transferred to
a hospital. If eclampsia is present when the
physician is called, the following routine is sug-
gested:

1. Absolute bed rest in a quiet darkened room
under constant surveillance by a trained nurse or
doctor. The head of the bed should be elevated
about 18 in. to reduce the possibility of acute
pulmonary edema.

2. Oxygen by nasal catheter (6 liters per min-
ute) should be administered if available.

3. A sphygmomanometer cuff should be kept
continuously on the patient’s arm, and the blood
pressure should be taken every ten minutes or
more often if hypotensive drugs are being used.

4. A Foley catheter should be inserted into the
bladder and an accurate intake-output chart
should be kept with special note made if urinary
output is less than 20 cc. per hour. Total intra-
venous intake in twenty-four hours should not
exceed 1,500 cc. plus output for the preceding
twenty-four hours.

5. The urine should be checked every four
hours for albumin— quantitatively if possible.

6. A hematocrit should be done daily if possi-
ble; also, nonprotein nitrogen, serum electro-
lvtes, and blood sugar should be checked.

7. A No 18-gauge needle should be inserted
into an arm vein, and blood should be withdrawn
for type and crossmatch. An infusion set with a
Y tube (so that blood can be run in if necessary)
is attached to a bottle of 1,000 cc. of 5 per cent
glucose in water containing 20 gm. of MgSCR.
If the patient is in the hospital or if the doctor
is prepared to sit by the patient and “titrate the
infusion against blood pressure changes, then
hypotensive drugs may be used. In our experi-
ence, the addition of 20 mg. of Apresoline and
5 mg. of veratrum alkaloids to the foregoing
solution is most satisfactory. The infusion is start-
ed at 20 drops per minute and thereafter reg-
ulated according to response. If desired, addi-
tional magnesium may be given intramuscularly
as 50 per cent MgSCb solution, while frequently
checking the patient’s tendon reflexes. Recent
work by McCall and Sass,12 Cheslev and Tep-
per,13 and Hall14 indicates that magnesium sul-
phate is still the most potent antieclamptic drug.

8. The blood pressure should be taken every
five minutes for the first two hours and then
every fifteen minutes, and a level of 110-140/
60-90 mm. Hg should be maintained if possible.

9. A single 250-mg. intravenous dose of Dia-
mox may help by diuresis and promotion of an
acidotic tendency.

10. The development of pulmonary edema and
any tendency to aspirate vomitus should be
watched. The nose and mouth must be kept free
of secretions.

11. Tracheotomy is advocated if respiratory
embarrassment from retained secretions occurs.
Collins15 attributed the fall in maternal mortality
in his series from 8 to 3 per cent largely to the
introduction of this measure.

12. Fetal heart tones should be recorded every
half hour. At the same time, the maternal pidse,
respiratory rate, and tendon reflexes are recorded
and the chest is auscultated as indicated.

13. If cardiac failure develops, or if the pulse
rate exceeds 120 per minute, digitalis should be
administered intravenously.

14. During the seizure:

a. Loosen the patient’s clothing if tight
and restrain as gently as possible.

b. Place a padded tongue depressor be-
tween her teeth.

c. Slowly inject 0.25 to 0.5 gm. of Sodium
Amytal intravenously. Avoid overseda-
tion, especially with barbiturates, for
their effects on the cerebral circulation
closely resemble the effects of eclamp-
sia.12 If the respiratory rate is less than
14 per minute, don't sedate further.

When convulsions have been controlled for
twenty-four hours, a careful vaginal examination
is carried out to assess the capacity of the pelvis
and the state of the cervix. If the cervix is favor-
able, labor is induced by rupture of the mem-
branes without Pitocin, although the latter mav
be used with care. If the cervix is not “ripe,” the
patient should be transferred to the hospital and
a cesarean section should be performed unless
contraindicated by some special circumstance.

In cases resistant to intensive therapv, and
especially in those characterized bv fulminating
onset, the pregnancy should be terminated as
soon as possible. Even at the thirtieth week of
pregnancy, the baby in an eclamptic mother has
probably less chance in utero than it has in the
premature nursery, while continuance of the
pregnancy definitely jeopardizes the life of the
mother. In the last few weeks of pregnancy,
there should be no hesitation in emptying the
uterus bv induction of labor or cesarean section
under local anesthesia.

298

THE JOURNAL-LANCET

The danger of eclampsia should be kept in
mind during the first forty-eight hours post par-
tum, and these seizures are treated as seriously
as those in the ante- and intrapartum periods.
Following delivery, oxytocics and estrogens
should he avoided, and ice packs should not be
applied to the abdomen for these tend to increase
blood pressure.

15. When the patient becomes lucid, oral fluids
should be forced and a low sodium, low carbo-
hydrate, high protein diet is indicated if urinary
output is satisfactory. Mild sedation should be
continued, such as 1 gr. of phenobarbital every
eight hours, and a 50 per cent solution of mag-
nesium sulphate should be deeply injected into
the gluteal muscles as required.

INTRAPARTUM EMERGENCIES

Prolapse of the cord occurs in about 1 of every
300 deliveries16 and is especially associated with
prematurity, manipulations (such as version,
surgical induction of labor when the presenting
part is not engaged in the pelvis), a long cord,
and any cause of nonengagement of the present-
ing part. Mengert and Longwell17 found this
condition in association with about 14 per cent
of shoulder presentations. The immediate danger
to the fetus is obvious, but it should be remem-
bered that the underlying cause may also en-
danger the mother’s life as in cases of malpres-
entation, placenta previa, and so forth. Man-
agement should be to:

1. Rule out underlying complications which
may be dangerous to the mother, for example,
find out whether there is a history of bleeding or
an obvious malpresentation.

2. Ascertain if the baby is alive from cord
pulsation and fetal heart tones.

3. Ascertain the dilatation of the cervix.

If no underlying complications are present and
the baby is dead, intervention is not required
and the patient is allowed to deliver spontan-
eously.

If the baby is alive, the following first-aid
measures are instituted: ( 1) the mother is placed
in knee-chest or Trendelenburg position to re-
duce pressure on cord, (2) the presenting part
is elevated by a hand in the vagina, and (3)
oxygen is given to the mother if available.

Further management depends upon the stage
of cervical dilatation. Thus:

1. If the cervix is dilated less than 3 cm., the
patient should be transferred to the hospital with
the first-aid measures continued meanwhile.
Cesarean section would be the treatment of
choice in these cases if facilities were available.

2. If the cervix is dilated 3 to 7 cm., the loop

of cord may be wrapped in sterile gauze and
pushed above the presenting part, and a tight
binder is applied to the abdomen. If, at this
stage, the breech presents, one leg may be pulled
down through the cervix to minimize the possi-
bility of recurrence. Should shoulder presenta-
tion develop, gentle attempts at version may be
carried out, but transfer to the hospital is pre-
ferable, since rupture of the uterus may result
from iatrogenic trauma or impacted shoulder.

3. If the cervix is dilated 7 cm. or more, the
baby should be delivered as soon as possible by
careful version and extraction with the help of
Diihrssen’s incisions placed at 10, 2, and 6 o’clock
if necessary.

Dystocia. In any case of delayed labor, the
general condition of the patient should be deter-
mined. The abdomen is examined to ascertain
if the uterus is contracting normally and if tone
and tenderness are within normal limits. At the
same time, the presentation, attitude, position,
and relationship of the fetus to the pelvic brim
should be assessed. Any abnormality, such as
twins or hydramnios, should be noted, and the
fetal heart tones should be checked. Vaginal
examination is carried out to assess pelvic ca-
pacity, cervical dilatation and effacement, and
position and station of the presenting part during
and between contractions as well to find out
whether or not the membranes are ruptured and
whether any tumor, including a full bladder, is
obstructing descent. One adequate examination
such as this saves many babies and mothers.

Delay in the first stage, whether from inertia
or abnormalities of passenger or passages, should
be recognized early. There is usually ample time
for transfer to the hospital. Prolongation of the
first stage of labor over twenty-four hours calls
for intervention unless good progress is being
made at that time. Fewer “failed forceps’’ are
now being seen in cases of delay in the first stage
of labor, and the greater number of cesarean
sections has resulted in a better prognosis for
mother and baby. Generally, Pitocin stimula-
tion should not be used even in cases of hypo-
tonic inertia unless the patient is in the hospital
and under careful observation. Most “failed
forceps” are due to attempts at delivery when a
malposition, especially occipitoposterior, or even
malpresentation is present; when the cervix is not
fully dilated; when the presenting part is too
high (thick caput); when obstruction to descent
is present; or when a contraction ring is present,
which is found in only 2 per cent of cases. The
maternal mortality in cases of “failed forceps” has
been reported as high as 5 per cent with a fetal
mortality of 40 per cent. It is interesting to note

JULY 1958

299

that after admission to the hospital, 85 per cent
of the women are delivered vaginally, either
spontaneously or by forceps. Only about 15 per
cent require delivery by the abdominal route. 1S

Delay in the second stage of labor. Malposi-
tions, such as occipitoposterior, rarely present
difficulty unless the pelvis is small. In a pri-
migravid patient, rotation to the occipitoan-
terior position and forceps delivery are usually
required. In a multigravid patient, delivery in
the posterior position by forceps is permissible,
for the fetal head is already molded for this
type of delivery.

Face presentation rarely gives trouble except
in the mentoposterior position when rotation to
the mentoanterior position is required before
forceps extraction is attempted unless the child
is premature or the pelvis is very roomy.

If the breech is allowed to deliver spontan-
eously until the shoulders are born, such compli-
cations as the nuchal position of the arms very
rarely occur. Lovset’s maneuver generally solves
this problem, although deep anesthesia is re-
quired. The most important factor in success-
fully delivering the head, by whatever means, is
the application of suprapubic pressure until the
head is well down in the pelvis. If the occiput
is in the posterior position, rotation to anterior is
required before delivery of the head is attempted
either by forceps or shoulder traction and supra-
pubic pressure.

If gentle attempts at conversion to vertex or
breech fail in cases of shoulder or brow presen-
tation with a mature child, transfer to the hos-
pital is mandatory, for rupture of the uterus is
likely. Embrvotomy may be resorted to if no
other treatment is available, but the danger of
trauma to the mother is great.

POSTPARTUM EMERGENCIES

Early postpartum hemorrhage. Etiology:

1. Lacerations of vagina, cervix, and uterus.

2. Inertia— uterine atony associated with 86.6
per cent of cases of early postpartum hemor-
rhage.19

3. A tendency to postpartum hemorrhage as
shown by multiparity or previous history.

4. Multiple pregnancy (large site and often
inertia).

5. Faulty management of the third stage.

6. Fibromyomata — preventing adequate re-
traction of the uterus.

7. Ring constriction— retaining the placenta.

8. Abruptio (especially the Couvelaire uter-
us) and placenta previa.

9. Partial placenta accreta or attempts at re-
moval of a complete accreta.

10. Inversion — occurs in 1 of 30,000 deliv-
eries.-9

Prophylaxis :

1. Administer oxytocics intravenously with
birth of the anterior shoulder or even post par-
turn after ensuring that there is no twin. If
available, blood should be given to replace loss.

2. Examine the vagina and cervix with a
speculum after every delivery and repair lacera-
tions.

Management:

1. Massage the uterus and express clots. Keep
a hand resting on the fundus especially in obese
patients.

2. Give oxytocics ( Pitocin and Ergotrate ) in-
travenously.

3. Manual removal of the placenta and ex-
ploration of the uterus should be carried out
under 1/6 gr. of morphine administered intra-
venously if no other anesthesia is available.
Examine the placenta after delivery to exclude
succenturiate lobes or retained fragments which
may cause further hemorrhage.

4. If rupture of the uterus, inversion, and so
forth have been excluded, then compress the
uterus bimanually with one hand on the abdo-
men and the other in the anterior fornix.

5. Give an intra-uterine douche with sterile
water at 116° F. with a small quantity of iodine
added.

6. Pack the uterus with oxidized cellulose
gauze (Oxycel). This is much more effective
than ordinary gauze packing. With a regular
gauze roll it is difficult to pack the uterus effec-
tively and instead of its acting as an adequate
tamponade, it tends to act as a wick which con-
ducts blood to the vagina.

After the uterus has been packed and the
bleeding adequately controlled, the patient
should be immediately removed to the hospital.

If bleeding is controlled, the Oxycel gauze
need not be removed, for, after about forty-eight
hours, the gauze liquefies and is expelled through
the cervix. The patient’s temperature frequently
rises to about 102° F. on the third or fourth day
despite prophylactic antibiotics. Occasionally, it
is necessary to remove some Oxycel from the cer-
vical canal about the third day in order to estab-
lish drainage.

7. If bleeding continues despite packing, lapa-
rotomy with repair of the uterus ii ruptured,
ligation of uterine arteries, or hysterectomy are
carried out as required.

If inversion is present, shock is out of propor-
tion to blood loss. An attempt at replacement
should be made and the patient transferred to
the hospital immediately, for the maternal

300

THE JOURNAL-LANCET

mortality, even in recognized and treated eases,
is about 12 per cent.-1

If, at the time of manual exploration of the
uterus, a diagnosis of placenta accreta or partial
accreta is made, attempts at removal should he
abandoned, the uterus packed with Oxycel
gauze, and the patient transferred to the hospital
with shock therapy continued meanwhile.

Before leaving the subject of manual removal,
it is interesting to note that many practitioners
who embark upon a midforceps operation hesi-
tate to manually remove a placenta. With care
and antibiotics, the latter is by far the safer
procedure.

Postpartum shock without hemorrhage may
occur in patients in whom Crede expression of
the placenta has been persistently attempted or
to whom Pituitrin has been given. The possibil-
ity of pulmonary infarction should be borne in
mind. The description by Lushbaugh and Stein-
er-’- in 1942 has explained some cases of sudden
death associated with acute respiratory embar-
rassment during labor or in the immediate post-
partum period. The treatment is the same as
for pulmonary infarction except that if amniotic
fluid embolism is suspected (hypertonic con-
tractions in labor, and so forth ) and the patient
survives, she should be watched for the develop-
ment of hypofibrinogenemia.

Paravaginal hematoma should be suspected if
the patient complains of perineal pain and shock
develops some hours post partum. The diagnosis
is readily made if perineal and rectal pain, per-
sistent despite 1 gr. codeine, are investigated by
vaginal and rectal examination. The hematoma
must be evacuated and bleeding points ligated.
The vagina should be packed with gauze to
effect tamponade.

Ruptured perineum is not generally serious,
even if the anal sphincter is involved, provided
it is carefully repaired under aseptic conditions.
If asepsis is in doubt, prophylactic antibiotics
should be given. Confinement of the bowels
post partum is not essential, but a low residue
diet is desirable for an optimum result.

Secondary postpartum hemorrhage is due to
retained placental fragments in a large propor-
tion of cases— 44.4 per cent of a series reported
by Lester and associates19— and so many cases
can be avoided if every placenta is carefully
examined and manual exploration of the uterus
is carried out where doubt exists. The manage-
ment of such a case consists of treating shock
with compatible blood and transferring the
patient to the hospital. If bleeding is very
severe, manual exploration should be carried out
and the uterus packed. Oxytocics should be

given and transfer to the hospital effected be-
cause hysterectomy may be required.

CONCLUSIONS

A preventable maternal death is a tragedy un-
equalled in medical practice, and the memory of
the wild-eyed father and whimpering motherless
children is not easily forgotten. The appalling
proportion of maternal deaths which are pre-
ventable is emphasized by careful analysis of
maternal mortality reports.

4 he Minnesota Mortality Study23 covering the
period 1950 through 1954 illustrates this point
only too well (table 3). In this study, 45 per
cent of obstetric deaths were ruled preventable,
and this rate was 2M times higher in rural areas
than in large cities where better hospital facil-
ities were available. Hemorrhage constituted
about 50 per cent of preventable deaths. About
one-half of these were due to lacerations of the
cervix or rupture of the uterus associated with
the injudicious use of Pitoein, the perpetration
of accouchement force, and the use of internal
version when it was clearly contraindicated. The
other half of hemorrhagic deaths resulted from
failure to use oxytocic drugs, such as Pitoein, in
cases of uterine atony. It is interesting to note
that toxemia of pregnancy was the second most
common cause of maternal death and that, in
this group, most preventable deaths were due to
failure to treat fulminating cases vigorously.

The following recommendations are made
with a view to reducing maternal deaths:

1. All obstetric care should be based on the
availablity of a hospital with adequate facilities
for blood transfusion, specialist consultation,
and major surgery.

2. The importance of prenatal care should

TABLE 3

OBSTETRIC CAUSES OF DEATH AND PREVENT ABILITY,
1950-1954

Causes of death

No.

Per

cent

Prevent-

able

Per cent
of total
preventable
deaths

Hemorrhage

48

27.1

37

46.8

Toxemia

36

20,3

13

16,5

Infection

25

14.1

8

10.1

Heart disease

13

7,3

3

3.8

Anesthesia

10

5.7

7

8.9

Amniotic Unit]
embolism

9

5.1

0

0.0

Air embolism

6

3.4

2

2.5

Chorionephithelioma

5

2.8

0

0.0

Others

25

14.1

9

11.4

Total

177

99.9

79

100.0

JULY 1958

301

be realized in the selection of poor risk pa-
tients for specialist care and delivery in a fully
equipped obstetric department.

3. In remote areas where hospital facilities
are inadequate, a specialist-manned mobile emer-
gency service should be set up. This team should
be available at all times to assist the rural
practitioner with obstetric emergencies. The

service should be based on a large maternity
hospital and should have equipment for blood
transfusions and major surgery aboard ambu-
lance, boat, or helicopter.

4. In mountainous or island regions, a heli-
copter should be available for rapid transporta-
tion of patients to a hospital or of “the flying
squad” to the bedside of the patient in extremis.

REEERENI :ES

1. Dewhurst, C. J.: Emergency obstetrical service; review of

489 cases in Manchester area. Lancet 2:746, 1952.

2. Word, B.: Ruptured tubal pregnancy. Obst. & Gynec. 8:

627, 1956.

3. Maternal mortality. U.S. Dept, of Health, Education and
Welfare, Vital Statistics Vol. 46, No. 17, 1957.

4. Kistner, R. W., Gorbach, A. C., and Smith, G. V.: Cer-
vical cancer in pregnancy. Obst. & Gynec. 9:554, 1957.

5. Ferguson, J. H.: Rupture of marginal sinus of placenta. Am.
J. Obst. & Gynec. 69:995, 1955.

6. Johnson, H. W.: Conservative management of some varieties
of placenta previa. Am. J. Obst. & Gynec. 50:248, 1945.

7. Macafee, C. H. G.: Placenta praevia — study of 174 cases.

J. Obst. & Gynaec. Brit. Emp. 52:313, 1945.

8. Borst, J. G. G.: Protein catabolism in uraemia; effects of

protein-free diet, infections, and blood transfusions. Lancet
1:824, 1948.

9. Bull, G. M., Joekes, A. M., and Lowe, K. G.: Conservative
treatment of anuric uraemia. Lancet 2:229, 1949.

10. Maternal mortality. U.S. Dept, of Health, Education and
Welfare, Vital Statistics Vol. 44, No. 14, 1956.

11. Hamlin, R. H. J . : Prevention of eclampsia and pre-eclamp-
sia. Lancet 1:64, 1952.

12. McCall, M. L., and Sass, D.: Action of magnesium sulfate
on cerebral circulation and metabolism in toxemia of preg-
nancy. Am. J. Obst. & Gynec. 71:1089, 1956.

13. Chesley, L. C., and Tepper, I.: Plasma levels of magnesium

attained in magnesium sulfate therapy for preeclampsia and
eclampsia. S. Clin. North America 37(2) :353, 1957.

14. Hall, D. G.: Serum magnesium in pregnancy. Obst. &

Gynec. 9:158, 1957.

15. Collins, C. G.: Rationale and value of tracheotomy in se-

vere preeclampsia and eclampsia. Postgrad. Med. 17:259,
1955.

16. Dilworth, E. E., and Ward, J. V.: Prolapse of the um-

bilical cord. Am. J. Obst. & Gynec. 73:1088, 1957.

17. Mengert, W. F., and Long well,- F. H.: Prolapse of um-

bilical cord; analysis of 58 cases. Am. J. Obst. & Gynec.
40:79, 1940.

18. Evers, H. H.: Obstetrical emergencies. Practitioner 168:

347, 1952.

19. Lester, W. M., and others: Role of retained placental frag-
ments in immediate and delayed postpartum hemorrhage. Am.
J. Obst. & Gynec. 72:1214, 1956.

20. McCullagh, W. McK. II.: Inversion of uterus; report on 3
cases and analysis of 233 recently recorded cases. J. Obst. &
Gynaec. Brit. Emp. 32:280, 1925.

21. Bell, J. E., Wilson, G. F., and Wilson, L. A.: Puerperal

inversion of uterus. Am. J. Obst. & Gynec. 66:767, 1953.

22. Lushbaugh, C. C., and Steiner, P. E.: Additional observa-
tions on maternal pulmonary embolism by amniotic fluid. Am.
J. Obst. & Gynec. 48:833, 1942.

23. Barno, A., Freeman, D. W., and Bellville, T. P.: Minne-
sota maternal mortality study; five-year general summary,
1950-1954. Obst. & Gynec. 9:336, 1957.

For pelvic repair, buried dermal grafts are useful either to replace absent
tissue or to strengthen existing fascia. Grafted tissue must ( 1 ) be similar in
structure to the endopelvic fascia; (2) be capable of burial in the endopelvic
fascia and able to develop its own blood vessels for survival; (3) blend into
and become a functioning part of the endopelvic fascia; and (4) strengthen
the receiving tissue and lend support to nearby structures. A full-thickness
dermal autograft best fulfills these requirements.

Cysts seldom form from hair follices or glands buried in the dermis. Fol-
licles and glandular structures degenerate, but the parenchymal firoblast cells
and dense network of collagen fibers survive.

A thick epidermal skin flap is elevated from the abdomen with a derma-
tome. The dermis is removed in full thickness and placed in normal saline
solution. The raised skin flap is then sutured back in place, and a pressure
dressing is applied. A bloodless field should be maintained while the dermal
graft is being placed.

In 2 patients who had cystoeeles with stress incontinence and in 1 patient
who had an enteroeele with a prolapsed vaginal cuff, buried dermal grafts
were completely satisfactory after eighteen and six months, respectively.

John E. Barrett, M.D., Lyndon, A. Peer, M.D., and Sadar I. S. Walia, M.D., St. Barnabas
Medical Center, Newark, New Jersey. Obst. & Gynec. 11:70-73, 1958.

302

THE JOURNAL-LANCET

Erythema Nodosum

KENNETH E. SWAIMAN, M.D., and
RICHARD B. RAILE, M.D.

Minneapolis, Minnesota

CASE REPORT

An 8-year-old Indian boy was admitted to Minneapolis
General Hospital on February 11, 1957, witli a two-day
history of painful, swollen, red blotches on his shins. A
week prior to admission, he had a slight cough for a few
days, without fever, which was treated with proprietary
cough drops. He was then in apparent good health un-
til two days prior to admission when, after seeing a
movie, he returned to his maternal grandmother’s house
and complained of pain in his legs. During the next few
hours' he noted development of the eruption, fever of
an undetermined degree, and increasing pain over his
lower legs. He was seen the following day in the out-
patient department and was admitted to the hospital
for evaluation. He had no joint pain and no pain in any
areas not involved by the skin lesions. He had taken no
drugs or tonics. Past history revealed that he had a
negative Mantoux test and a normal chest roentgeno-
gram six months before admission. He was hospitalized
at Minneapolis General Hospital in 1954 witli typical
scarlet fever. At that time, his Mantoux test with 1 : 1,000
old tuberculin was read as negative. During that admis-
sion, a grade 1 systolic murmur was noted. He had no
recent sore throats. When an infant, the patient had a
pneumonia which was not serious enough to warrant hos-
pitalization. He had not previously experienced a similar
skin eruption at any time, or had he ever had joint ten-
derness or swelling. The family history revealed that his
maternal grandmother had “pleurisy” several months
before his admission. She had no medical care for this
illness. A stepsister of his mother was discharged from
a tuberculosis sanatorium in 1955 after treatment for
pulmonary tuberculosis. The patient had never been out
of the State of Minnesota.

Physical examination revealed a well-nourished Indian
hov who complained of pain in his legs whenever they
were touched or moved. No joint pain or joint swelling
was apparent. There were numerous warm, very tender,
purple to yellow-lmed lesions on both anterior tibial areas
and over both anterior thighs (figure 1). These lesions
were from 1 to 5 cm. in diameter. The tympanic mem-
branes were scarred bilaterally but not acutely inflamed.
Examination of the eyes, nose, and oropharynx was un-
remarkable. The neck was supple. The lung fields were
clear to percussion and auscultation There was a sinus
tachycardia with the pulmonic second sound greater than
the aortic second sound. There was no precordial bulge.
A grade 1 to 2 systolic murmur was present over the
pulmonic area and radiated to the entire precordial area.
No thrill was palpable. There was no apparent cardio-
megalv. The examination of the abdomen was not ab-

kenneth f. swaiman is chief resident in pediatrics
at the University of Minnesota, richard b. raile
is assistant professor of pediatrics at the University
of Minnesota.

normal; the liver and spleen were not enlarged. No
clubbing, edema, or cyanosis of the extremities was
noted. The genitalia were normal. Neurologic examina-
tion was noncontributory. The blood pressure was 104/
62/30, pulse 120, respirations 28, and temperature 103. 8‘
orally. Lymphadenopathv was insignificant. Erythema
nodosum was diagnosed from the typical appearance
of the skin lesions.

Initial laboratory studies revealed a hemogram consist-
ing of hemoglobin 11.9 gm. per cent, white blood count
16,950 with 78 per cent polymorphonuclears, 20 per
cent lymphocytes, 1 per cent monocytes, and 1 per cent
eosinophils. Sedimentation rate was 104 mm. per hour.
Urinalysis was normal. The chest roentgenogram was
reported negative. An antistreptolysin O titer of 333
Todd units (borderline significant in our laboratory) was
also reported. The electrocardiogram was normal in
every respect (P-R .12). Cultures of the nasal flora re-
vealed a very occasional colony of Staphylococcus, and
cultures of the throat revealed a mixture of organisms,
including an occasional colony of beta hemolytic strep-
tococcus on human blood agar. After forty-eight hours,
the 1:1,000 old tuberculin skin test was strongly positive.
Triple fungous skin tests were all negative after fortv-
eight hours (figure 2). The hospital course was marked
by high fevers and leg pain which was helped somewhat
by salicylates. February 21, 1957, he was transferred
to the county tuberculosis sanatorium to await results of
gastric washings. Subsequently, two gastric washings
were reported positive for acid-fast bacilli. Repeat
roentgenogram and electrocardiogram were normal. Treat-
ment of the tuberculosis was begun with a regimen of
150 mg. of isoniazid daily and 4.0 gm. of para-amino-
salicylic acid daily. Therapy was continued for one year.
At present, he is asymptomatic, and his most recent
sedimentation rate was 15 mm. per hour.

NATURE OF LESIONS IN ERYTHEMA NODOSUM

No better description of the lesions can be had
than the English translation of Hebra’s descrip-
tion of the disease1— “Light-red raised nodules
tender to the touch and mainly situated on the
legs. In many cases, the eruption is preceded
by a slight temperature elevation or even chills;
often, however, the patient has no previous
warning of the disease before he sees or feels
the nodes. They occur as a rule in various sizes,
the smallest the size of a pea and the largest
that of a closed fist. The individual nodules are
usually discrete and, at first, pale red with a
faint gold tinge; at a later stage, they turn dark
red, then livid, and, after the redness has dis-
appeared, the lesions persist for a long time in
the form of yellowish pigmentation. These shift-

JULY 1958

303

Fig. 1. Bruise-like nodose lesions on legs in all stages
of evolution, diffusely involving the anterior tibial sur-
faees bilaterally. ( Photograph taken on fifth day of hos-
pitalization).

Fig. 2. Strongly positive 1:1,000 O.T. skin test on right
arm seventv-two hours after intradermal injection. Note
negative triple fungous skin tests after seventy-two hours
on left arm.

ings of color are the same as those occurring
after a bruise, and, for this reason, the name
dermatitis contusiformis has been used by some
authors.”

CLINICAL MANIFESTATIONS

In the vast majority of cases, erythema nodosum
is a self-limited entity. The average duration is
less than six weeks. An occasional case may be-
come chronic and persist for months or years. -
Chronic cases occur verv rarely in the pediatric
population. In one series, 90 per cent of patients
were fully recovered after eight weeks.3

About one-third of the patients manifest a mild
anemia. The white blood count varies greatly,
but a tvpical report reveals the following:3

White blood count

Per cent of cases

Less than 6,000

6

Between 6,000 and 1 (),()()()

42

Between 10,000 and 20,000

50

Above 20,000

2

The sedimentation rate is consistently elevated,
and the average figure is about 80 mm. per hour
(Westergren).4 In several large series, all pa-
tients had fever.3"'-0 The usual range was from
100 to 102°.

Phlyctenules and conjunctivitis have often
been reported in conjunction with erythema no-
dosum.7 True joint pain is uncommon, but pain
over the affected skin areas is almost universal.
Several investigators who reported large series
claim to have never seen associated arthralgia or
arthritis. Although information is scarce, the in-
cidence would appear to be higher in the winter
and spring seasons. It is primarily a disease of
the second, third, and fourth decades.8 The
youngest patient reported was 7 months old. It
is rare before the age of 2.

ETIOLOGY

Review of the literature reveals that ervthema
nodosum is associated with numerous diseases
and drugs. The question of the mechanism of
association has not been settled. As far as can
be ascertained, all lesions of erythema nodosum
of comparable age have similar histologic struc-
ture/'

The theory that the disease has but one eti-
ology, that is, viral infection, which is in some
way enhanced in the presence of certain infec-
tions and chemical environments has several pro-
ponents.10 There are some who favor toxic eti-
ology and others who believe concurrent infec-
tions are responsible for erythema nodosum.
However, a large segment of scientific opinion
appears to embrace the theory that the disease
is a nonspecific hypersensitivity reaction1112 that
can be triggered bv numerous stimuli. Several
histologic studies note striking similarities be-
tween the vascular lesions of erythema nodosum
and periarteritis nodosa.13 The absence of com-
plete obliteration of the arteriolar vascular chan-
nels in erythema nodosum prevents the fat nec-
rosis seen in erythema induration.

It appears that the predominant diseases as-
sociated with erythema nodosum— tuberculosis
in Scandinavia,1 streptococcal disease in the
northern United States,1112 coccidioidomycosis in
California,14 and lymphogranuloma venereum15
and tuberculosis in India— are invariably corre-
lated with disease frequence.

304

THE JOURNAL-LANCET

Treatment with sulfathiazole apparently in-
creases the incidence of erythema nodosum in
various diseases.1617 This problem will he dis-
cussed later.

COMMON ASSOCIATED DISEASES

Tuberculosis. Most American authors conclude
that tuberculosis usually is not the cause of ery-
thema nodosum in the United States. On the
other hand, authors from European countries
feel the opposite viewpoint holds for the disease
in Europe. In Stockholm, between 1942 and
1946, 58 per cent of the cases of erythema no-
dosum were associated with tuberculosis.8 In
addition, this study revealed that in the younger
age groups erythema nodosum was even more
often associated with tuberculosis. In childhood,
erythema nodosum occurred more often in males,
while it was more often associated with females
in adult life.8

In a series of 155 patients with erythema no-
dosum in Boston, collected over a thirty-year
period, only 4 (2.5 per cent) had active tubercu-
losis.1- Evidence has shown that pleurisy and
postprimary tuberculosis are more apt to dvelop
in a patient with a recently converted positive
Mantoux test who also has erythema nodosum
than in a person with a positive test who does
not have erythema nodosum.7

A comparison of studies of erythema nodosum
in various age groups points to the fact that
tuberculosis is an important factor when ery-
thema nodosum occurs in childhood but is a less
common factor in adulthood.18

Streptococcal disease. For a time, erythema
nodosum was considered to be a part of the
syndrome of rheumatic fever. However, the liter-
ature over the past twenty years repeatedly re-
veals that erythema nodosum associated with
rheumatic fever is an unusual occurrence. Sever-
al authors pointed out that a relatively large
number of their patients proved to have beta
hemolytic streptococci in their throat cultures.
No control studies are available to show how
many of their fellow patients had similar bacter-
iologic findings. The concensus of opinion is that
both erythema nodosum and rheumatic fever
may be sequelae to antecedent beta hemolytic
streptococcal infection.19 This would explain
the definite, but relatively rare, simultaneous
appearance of these two diseases. Cutaneous in-
jections of killed streptococci, streptococci broth
filtrate, and streptococcal nucleoproteins are re-
ported to have produced systemic reactions,
such as malaise, myalgia, fever, and new nodules,
in a high percentage of patients with erythema
nodosum and positive throat cultures for beta

hemolytic streptococci. Concurrent erythema
nodosum and acute rheumatic fever should be
diagnosed only in the presence of active carditis
and fulfillment of the other usually accepted
criteria in the diagnosis of rheumatic fever.20

Coccidioidomycosis. The relationship of coc-
cidioidomycosis to erythema nodosum was not
postulated until 1936. 14,21 Subsequently, it was
demonstrated that the disease was indeed found
with primary coccidioidomycosis.22 Ervthema
nodosum appears very soon after sensitivity to
the cutaneous coccidioidin test develops— two to
seventeen days after onset of disease. It is of
interest that in a series of 432 patients23 with
erythema nodosum and coccidioidomycosis, there
were no cases of systemic granulomatosis, where-
as 1 to 2 per cent of cases would be expected
to progress to the systemic disease.

Other diseases. Erythema nodosum occurs in
lymphogranuloma venereum when the Frei test
is at its maximum reaction. There are occasional
reports in which the disease is associated with
lues, leprosy, trichophytosis, meningococcemia,
rubeola, influenza, gonorrhea, pertussis, and sar-
coidosis. Several authors question the validity
of these reports, although the bulk of them are
well documented.10

Erythema nodosum and drugs. Erythema no-
dosum has been seen in conjunction with numer-
ous drugs, such as arsphenamine, salicylates,
antimony, halogens, phenacetin, and sulfona-
mides—particularly sulfathiazole.18

Studies have shown that when sulfathiazole is
given to patients with primary tuberculosis, ery-
thema nodosum develops with much greater fre-
quency than in control patients with primary
tuberculosis.17 This phenomenon was also noted
in conjunction with the treatment of streptococ-
cal disease.16 The logical conclusion is that the
drug is a provocative factor in erythema no-
dosum.15'24 Nevertheless, there are numerous
cases in which the offending drug appears to be
the primary causative agent. Certainly, no satis-
factory explanation of drug action, aside from
the general category of hypersensitivity reaction,
is available at this time.

COMMENT

The simultaneous occurrence of tuberculosis and
rheumatic fever is possible although improbable.
The case presented in this paper included several
laboratory reports which by themselves sug-
gested acute rheumatic fever. However, on care-
ful evaluation, the findings did not meet the
criteria necessary to diagnose rheumatic fever in
the face of the well-known accepted symptoms
of ervthema nodosum regardless of cause.

JULY 1958

305

SUMMARY

The case of an 8-year-old Indian boy with ery-
thema nodosum associated with primary tuber-

culosis is presented. A brief review of the clinical
picture and etiology of this condition is also pre-
sented.

REFERENCES

1. Hebra, cited by Lofgren, S.: Erythema nodosum; studies on
etiology and pathogenesis in 185 adult cases. Acta med. scan-
dinav. (Supp. 174) p. 1, 1946.

2. Harrison, T. R.: Principles of Internal Medicine. Philadel-

phia: The Blakiston Co., 1950.

3. Wasserma.v, E., and Yules, J.: Erythema nodosum: analysis
of 50 cases and review of the literature. Am. Pract. & Digest.
Treat. 2:772, 1951.

4. Johnson, C. C., Hanson, N. O., and Good, C. A.: Erythema
nodosum: possible significance of associated pulmonary hilar
adenopathy. Ann. Int. Med. 34:983, 1951.

5. Koch, H.: Erythema nodosum. Extrapulm. tuberk. 1:22, 1926.

6. Wali.gren, A.: Erythema nodosum, in Engel, S., and Pir-

quet, C.: Handbuch der Kindertuberkulose. Leipzig: Georg

Thieme, 1930, p. 809.

7. Holmdahl, K.: Course and prognosis in primary tubercu-

losis with erythema nodosum in children. Acta tuberc. scan-
dinav. (supp. 22) p. 1, 1950.

8. Lofgren, S.: Age distribution of erythema nodosum. Acta

med. scandinav. 136:241, 1950.

9. Lofgren, S., and Wahlgren, F.: On the histopathology of

erythema nodosum: Acta dermat.-venereol. 29:1, 1949.

10. Miescher, cited by Doxiadis, S. A.: Erythema nodosum in
18 children. Medicine 30:283, 1951.

11. Spink, W. W.: Pathogenesis of erythema nodosum, with spe-
cial reference to tuberculosis, streptococcic infection and rheu-
matic fever. Arch. Int. Med. 59:65, 1937.

12. Favour, C. B., and Sosman, M. C.: Erythema nodosum.

Arch. Int. Med. 80:435, 1947.

13. Winer, L. H.: Histopathology of nodose lesions of lower ex-
tremities. Arch. Dermat. & Syph. 63:347, 1951.

14. Gifford, M. A.: Erythema nodosum in San Joaquin fever.

Ann. Report of Kern County Department of Public Health,
July 1, 1936, to June 30, 1937. Bakersfield: California Press,
pages 48-54.

15. Simpson, R. G.: Erythema nodosum; provocation phenom-

enon; with special reference to lymphogranuloma venereum
( Nicolas-Favre) . Dermatologica 101:94, 1950.

16. Doxiadis, S. A., and McLean, D.: Erythema nodosum in

children following administration of sulphathiazole. Arch. Dis.
Child. 23:273, 1948.

17. Rollof, S. I.: Erythema nodosum in association with sul-

phathiazole in children; clinical investigation with special ref-
erence to primary tuberculosis. Acta tuberc. Scandinav.
(supp. 24) p. 1, 1950.

18. Beerman, H.: Erythema nodosum; survey of some recent

literature. Am. J. M. Sc. 223:433, 1952.

19. Perry, C. B.: Aetiology of erythema nodosum. Brit. M. J.

2:843, 1944.

20. Iones, T. D.: Diagnosis of rheumatic fever. J.A.M.A. 126:

481, 1944.

21. Gifford, M. A.: Coccidioidomycosis in Kern County, Cali-

fornia. Proc. Pacific Sc. Cong. 5:791, 1939.

22. Dickson, E. C.: “Valley fever” of San Joaquin and fungus

coccidioidomycosis. California & West. Med. 47:151, 1937.

23. Smith, C. E.: Epidemiology of acute coccidioidomycosis with
erythema nodosum. (“San Joaquin” or “valley fever”). Am.
J. Pub. Health 30:600, 1940.

24. Lofgren, S.: Erythema nodosum following treatment with

sulfanilamide compounds. Acta med. Scandinav. 122:175,
1945.

Although the incidence is debatable, cardiac complications do occasionally
occur with infectious mononucleosis. Five cases of acute pericarditis and acute
myocarditis associated with proved infectious mononucleosis were recently
reported.

An abnormal electrocardiogram is the most frequent finding. Irregularities
include inverted and flattened T waves, occasional auriculoventricular conduc-
tion blocks, depression of the S-T segment, and nonspecific changes. Apical
systolic murmurs, pericardial friction rubs, and cardiac failure are the most
common physical signs.

The heart complications subside spontaneously in two to four months.
Symptomatic supportive treatment should include bed rest until serial cardio-
grams indicate that the process is quiescent.

B. H. Webster, M.D., St. Thomas Hospital, Nashville, Tennessee. Am. J. M. Sc. 234:62-70. 1957.

306

THE (OURNAL-LANCET

Fargo Tornado — Medical Aspects

MEDICAL DISASTER COMMITTEE,

ST. LUKE’S HOSPITAL,

Fargo, North Dakota

On June 20, 1957, a tornado swept through
the northern section of Fargo, North Da-
kota, resulting in the devastation of 100 square
blocks of the community, death of 11 persons,
hospitalization of 26 individuals, and treatment
of 141 patients in the emergency room of St.
Luke’s Hospital. The hospital was not damaged
by the tornado. It has been suggested that the
Disaster Committee of this hospital review its
experiences in handling the medical aspects of
this disaster as a benefit to other communities
in planning similar disaster committees. This
report will deal with 5 phases of the problem:
( 1 ) preliminary planning by the Disaster Com-
mittee to cope with the community disaster,
(2) the immediate steps taken to care for pa-
tients after this area was stricken, (3) actual
operation of the hospital and medical personnel
during the influx of casualties, (4) a resume
of the tvpes of cases encountered and their dis-
position, and (5) the measures deemed advis-
able in preparation for better management of
possible future disasters.

PRELIMINARY PLANS

Prior to last year’s tornado, the Disaster Com-
mittee of St. Luke’s Hospital had formulated
plans in anticipation of some local medical ex-
igency. The first aid facilities of the local police,
fire department, civil air patrol, and locally based
North Dakota' National Guard had been inves-
tigated. Discussions had been held with repre-
sentatives of the community’s private ambu-
lance service. The physical facilities of St. Luke’s
Hospital had been evaluated by the committee
in conjunction with key hospital personnel, and
such topics as bed utilization, expansion of emer-
gency room facilities, the use of nursing class-
rooms, and the emergency power facilities of the
hospital had been considered. Broad plans were
formulated, and, after this discussion, the hos-
pital ordered additional fracture equipment for
handling major injuries of the extremities. The

Members of the St. Luke’s Medical Disaster Com-
mittee are: Dr. G. A. Dodds, chairman ; Dr. D. T.
Lindsay, Dr. 11. A. Norum , Dr. P. O. Triggs, and
Mr. Byron Jackson, hospital administrator.

various contingencies in the event of disaster had
been considered and fairly detailed plans formu-
lated. However, no actual dress rehearsal was
conducted.

IMMEDIATE PREPARATION

The tornado which struck Fargo at 7:40 p.m.
on June 20 had been well forecasted by the
Weather Bureau, and the great majority of per-
sons in the path of destruction had either va-
cated their homes or taken refuge in their base-
ments. When the calamity became a reality,
there were 4 staff physicians in the hospital, 2
of whom were members of the Disaster Commit-
tee. These men and the intern and staff resident
of the hospital prepared immediately to receive
an abnormal number of emergency cases. At
this time, the electric power to the communities
of Fargo and Moorhead was out and, as a result,
the stand-by electric system of the hospital had
immediately come on. A cpiick check of the
emergency electrical outlets supply was made,
and all vital services were operative except the
elevators. There were no patients using Drinker
respirators, and the patients using oxygen tents
with electrical circulating fans were not in crit-
ical condition. It, therefore, was decided not
to move any patients into the areas of the hos-
pital in which emergency electrical outlets were
available. All nursing personnel were furnished
with flashlights, and, since the telephone system
in the Fargo area was not functioning, messen-
gers were dispatched to the homes of the key
physicians and nursing personnel who would be
needed to supplement the hospital staff. All
available wheel litters from the upper four floors
of the hospital were carried down stairways to
the ground floor to be available at the ambu-
lance and emergency room entrances. The hos-
pital cafeteria was selected as the first major ex-
pansion facility to be used as an annex for our
limited emergency room. Dining tables were
grouped appropriately, mattresses were placed
upon the tallies, and working areas were desig-
nated. One of the adjacent nursing classrooms
in a wing of the hospital was prepared as an
emergency treatment room. The second nursing

JULY 1958

307

classroom was made accessible but was not re-
quired. Extra supplies of sterile dressings and
suture sets were made available to the emer-
gency room areas. Several private rooms of the
hospital were converted into double rooms, and,
in a very short time, a full complement of nurs-
ing and operating-room personnel were ready
and at their stations. Off-duty nurses responded
without being summoned. The need for addi-
tional manual help to supplement the various
vital functions of the hospital was met without
difficulty by the large number of volunteer lay-
men who, with some technical competence, re-
ported voluntarily from the immediate neigh-
borhood and other areas of the community. Ev-
ery department of the hospital was well supplied
with help.

The actual care of tornado casualties began
with the arrival of a police squad car carrying a
man with a laceration of his back, his clothes
in tatters, and both the patient and his rescuer
completely covered with filth, ft was evident
that shortly there would be an unusual number
of hospital admissions, so a physician from each
hospital service checked the inpatient bed load
and arranged for immediate discharge of those
patients whose condition did not actually re-
quire them to remain hospitalized. This freed
several beds which subsequently were occupied
by tornado casualties. The casualties arrived by
ambulance, private cars, fire truck, police squad
car, on foot, and being carried by their friends
and neighbors. A number of the injured chil-
dren and a few adults were unidentified for sev-
eral hours. Emergency medical tags for identifi-
cation and recording the preliminary care were
improvised by a member of the hospital record
librarian staff. These tags proved invaluable.
The medical condition of the casualties was
evaluated as quickly as possible by the first phy-
sician who met them on arrival. The name and
diagnosis of the patient was placed upon the
identification tag, and temporary disposition was
given to the case. Those with obviously serious
injuries were admitted to the hospital or direct-
ed to an appropriate location in the hospital for
further specialized care. Persons with minor in-
juries were asked to take a place and wait for
further definitive therapy. Forty-five patients
were sent to the x-ray department for radio-
graphic studies, and persons with contusions and
lacerations were treated by methods deemed
appropriate at the time. Several of the more
seriously injured persons were those with skull
fractures and associated cerebral damage, which
resulted in severe convulsions. These patients
were given the highest priority of first aid and

medical care. All patients with penetrating
wounds were treated with prophylactic tetanus
antitoxin or with toxoid if they had been in the
armed services. The less severely injured people
who had to wait for medical care never com-
plained. One outstanding observation was the
complete lack of hysteria on the part of any of
the injured individuals or their families. In spite
of the fact that approximately 60 to 70 patients
entered the emergency room within the first hour
and one-half after the disaster occurred and were
often accompanied by members of their immedi-
ate families, in most instances, there was little
confusion.

OPERATION OF THE HOSPITAL

One of the most surprising aspects of the med-
ical care was the large number of professional
persons who appeared at the hospital without
being called. Thirty or 40 physicians worked
together on the emergency cases, and many from
the staff of St. John’s Hospital, Fargo, responded
immediately to offer their services. The full day-
time staff of St. Luke’s Hospital and all key in-
dividuals from the business office, pharmacy,
laboratory, radiology department, record librar-
ian’s office, hospital administrator’s office, and
the engineering department were present. Many
volunteers gave manual assistance in moving
beds, litters, mattresses, and oxygen tanks and
the many other jobs requiring a strong back and
a person able to follow directions . The possi-
bility of confusion was controlled by the excel-
lent work carried out by the hospital record
librarian and her staff who kept a complete ac-
count of all patients admitted to the emergency
room of the hospital, their addresses, the diag-
nosis of their difficulties, and the disposition of
their problems. This information was kept up-
to-date and immediately transmitted to repre-
sentatives of the local television and radio sta-
tions who, in turn, put the information on the
air. This resulted in a minimum of inquires
direct to the hospital telephone switchboard.
The medical record librarian of the hospital act-
ed as the liaison agent between the hospital and
the various news-gathering agencies. We can-
not emphasize too strongly the very valuable
help these agencies can render at the time of
a disaster and the necessity of maintaining close
coordination with them. A complete roster of
all persons injured and their conditions was
available within three hours after the tornado
struck the city. At the end of this period, the
halls of the hospital were cleared. All patients
had been either admitted to the hospital or sent
home.

308

THE JOURNAL-LANCET

TYPES OF CASES

On the evening of the disaster, a total of 67
patients were seen in the emergency room of
St. Luke’s Hospital, 26 of whom required hos-
pitalization. The breakdown on the type of case
seen is given in table 1. The following day 74
additional patients were treated in the emergen-
cy room. A breakdown of these cases is pre-
sented in table 2. It was interesting to note the
many puncture wounds from nails. The majority
of these wounds were in the feet, which occurred
when people walked around in the dark amidst
the debris of the tornado trying to recover their
possessions. Altogether 141 patients were treat-
ed in the forty-eight-hour period. It was noted
that the majority of the lacerations became in-
fected, which again emphasizes the fact that
such wounds should have been treated by de-
layed suture rather than primary closure. No
cases of tetanus developed.

It is worthy to mention that the press raised
the question of medical fees in the handling of
these unfortunate tornado victims. This inquiry
was prompted by the unfavorable publicity the
medical profession had been receiving in the
East at that particular time in a case which was
receiving nationwide attention. The local med-
ical profession decided not to charge any victim
of the tornado a professional fee for the emer-
gency medical care rendered. The onlv excep-
tions were patients who would require a pro-
longed hospital stay. This decision resulted in
a verv favorable editorial to the profession from
the area press.

FUTURE PLANS

A review was held by the Disaster Committee
two weeks after the Fargo tornado, and, in light
of our past experience, several additions to our
disaster plan were made. We felt that the rela-
tive success of the recent tornado medical care
program was largely due to the fact that it was
a limited disaster as far as injuries were con-
cerned, with a relatively large amount of profes-
sional help to care for these cases. It was our
feeling that in a more extensive catastrophe, seri-
ous weaknesses woidd have developed in our
planning. At present, our program is organized
under two headings — the hospital administra-
tive section and the medical section. First, in
considering the administrative duties, the most
important requirement is a ready supply of med-
ical identification tags with carbon or detach-
able duplicates for purposes of keeping track of
the names and tvpes of casualties arriving. In
addition, persons shoidd be assigned to inter-
view members of the family and others inquir-

ing about the condition of patients. A section
must be set up as a radio and press information
center. Personnel of the hospital administrative
office must be present to attend to the innumer-
able details requiring immediate decisions in
coping with the unusual problems arising. Hos-
pital nursing service must arrange for extra nurs-
ing coverage, recruitment of volunteers, and the
assignment of student nurses and graduates. Spe-
cial duty nurses for critically injured patients
must be provided. In the event of an extraordi-
nary catastrophe, the system used in the military
services of resupplying ambulances and first-aid
vehicles should be anticipated. Patients trans-
ported to the hospital in splints will deplete the
first-aid supplies of the vehicle bringing them,
and an exchange of equipment must be arranged
so that these vehicles can continue to function
effectively.

TABLE 1

PATIENTS SEEN AND TREATED THE EVENING OF THE
TORNADO, JUNE 20, 1957

Examined
Admitted and/or
to hospital treated

Total

Abrasions and contusions 4

7

11

Burns

1

1

Fractures:

Humerus, ribs, vertebra 1

1

Ankle, pelvis, vertebra 1

1

Femur, humerus 1

1

Clavicle 1

1

Fibula 1

1

Radius

1

1

Ribs

1

1

Multiple

2

2

Foreign bodies

i

i

Head injuries 10

i

ii

Lacerations 1

10

ii

Observation 0

16

22

Puncture wound

1

i

Total 26

41

67

TABLE 2

PATIENTS SEEN IN EMERGENCY

ROOM JUNE 21, 1957.

FROM CLEAN-UP

AREA

Abrasions and contusions

11

Burns

1

Foreign bodies

3

Possible fractures

2

Lacerations

8

Puncture wounds from nails

37

Observation

12

Total

74

JULY 1958

309

In the present disaster, no item of equipment
was in short supply. However, in a calamity of
greater proportions, a reserve supply of military
type canvas stretchers would make it much
easier to carry patients up and down stairways
in the event elevator services were interrupted.
Furthermore, these pieces of equipment are
readily stored and, if necessary, could serve as
beds. In our experience, patients with severe
head injuries comprised a significant proportion
of cases, and we found ourselves short of readily
portable oxygen equipment which could be util-
ized while these patients were undergoing radio-
graphic studies and being moved from the emer-
gency room to their hospital room or from there
to the operating room. Only small portable oxy-
gen tanks with face masks will properly serve
this purpose. The final facility which would be
most desirable in the event of an extensive dis-
aster would be a communication system between
the hospital and the actual disaster area, permit-
ting physicians caring for these patients to make
suitable advanced plans. Radio communications
direct to ambulances and police vehicles in the
field would be extremely helpful in order to in-
form the medical staff of more extensive expan-
sion. This communication system should be pow-
ered from the hospital’s emergency generator.

From the medical standpoint, the most impor-
tant thing is a team of physicians whose sole
function is to sort and direct the flow of casual-
ties upon arrival at the treatment center. A sec-
ond team of physicians and nurses should clean
up the patients and their wounds so that a more
adequate evaluation of the problem can be es-
tablished. The problem of patients covered with
debris was very acute in this instance. A third
team of physicians and nurses should handle the
minor injuries and wounds of patients not re-
quiring hospitalization. The more seriously in-
jured patients suffering from shock are best treat-
ed in an area designated as a “shock ward” prior
to their definitive hospital admission. This area
should be away from the commotion produced
by the How of persons with minor injuries. It
seems to us that a team of individuals to admin-
ister tetanus prophylaxis and record the same
on the patient’s medical tag would be valuable.
In a disaster not involving burns, the department
of radiology is indispensable and requires an

adequate number of x-ray technicians directed
by a physician and an extra supply of orderlies
and messengers to direct the influx of patients.
It is mandatory that the x-ray department have
auxiliary power facilities in the event that the
municipal electrical system fails. Many patients
with minor uncomplicated fractures could well
be treated without admission to the hospital by
application of plaster casts in an area adjacent
to the emergency room. These patients could be
treated by immediate fixation in plaster, with
the roentgenograms obtained as a matter of rec-
ord, without sending them to the radiology de-
partment before plaster is applied. This would
eliminate some confusion and duplication of ef-
fort. Cases requiring treatment in the operating
room are, of course, admitted to the hospital and,
preferably, all casualty victims should be ad-
mitted to one floor or unit of the hospital. Some-
one in authority should have the responsibility
of determining the priority of care in the oper-
ating room. This task would fall to the chief
or the acting chief of the surgical service of the
hospital. Nonsurgical problems would be su-
pervised by floor physicians working under a
medical chief.

CONCLUSION

In setting forth the preceding information, the
members of the St. Luke’s Hospital Disaster
Committee have purposely not referred to the
many excellent monographs and government
bulletins available on this subject. We are fa-
miliar with their contents but have limited our
comments to the results of our own experience.
We appreciate that it is a difficult task to per-
suade people to plan realistically for a catas-
trophe, but the time spent in proper planning
will be well rewarded if misfortune strikes. We
feel that good plans made for a calamity of small
magnitude can be heartily supported by laymen
and profesional people alike and that we do not
need to think in terms of a national emergency to
justify a complete disaster plan for a community
hospital. The Fargo tornado has heightened the
interest of cur community and our professional
people in preparation for sudden and extraordi-
nary misfortune, and, as a result, our own
efforts in the future will be considerably more
effective than in the recent past.

310

THE JOURNAL-LANCET

Harold Slieely Diehl, M.D.

Bv J. ARTHUR MYERS, M.D.

When a physician makes notable contributions
over several decades, it is appropriate that a
summary of his life and accomplishments be brought
to the attention of the medical profession. In such
a life, there often is much that others can emulate
to their great advantage. This is especiallv true of
the life of Harold Diehl. He was born in Nittany,
Pennsylvania, on August 4, 1891, attended public
schools at Nittany and Middleburg, and was a stu-
dent at the York Collegiate Institute, York, Pennsvl-
vania, in 1907 and 1908. He entered Gettysburg
College from which he received the degree of Bach-
elor of Arts in 1912. For the next two years, he was
assistant principal and teacher of mathematics in the
high school at Fulton, New York.

After spending the summer of 1914 at Syracuse
University, he entered the University of Minnesota
School of Medicine. This was made possible bv car-
rying a part-time teaching position in chemistry at
Augsburg College in Minneapolis. In 1918, he re-
ceived the degree of Doctor of Medicine and served
as intern and physician in France with the United
States Base Hospital 26 in World War I. From 1919
to 1920, he was Director of the Northern Division of
the American Red Cross Commission to Poland. He
then entered the University of Minnesota Graduate
School and received the degree of Master of Arts in
medicine in 1921. That year the Polish government
awarded him the medal of Polonia Restituta. In
1935, Gettysburg College called Dr. Diehl back to
bestow upon him the honorary degree of Doctor of
Science.

In 1921, he became director of the Student Health
Service, University of Minnesota, and instructor in
Pathology and Public Health. He was made assist-
ant professor of Preventive Medicine and Public
Health in 1922, was promoted to the rank of asso-
ciate professor in 1924, and was made professor in
1929.

In 1935, he resigned the directorship of the Stu-
dent Health Service to become dean of the Med-
ical Sciences and continued in this capacity through
1957 when he was granted a leave of absence to
accept another position.

Dr. Diehl organized the Department of Preventive
Medicine and Public Health in 1922 and served as
its head until 1936 when he invited Dr. Gavlord
Anderson of Harvard University to take over this
department. Since that time, he has continued his
appointment in this department, and he participated
with Dr. Anderson in founding the School of Public
Health in 1944.

HAROLD SIIEELY DIEHL

On September 7, 1921, he married Julia Louise
Mills, who was then a teacher of Home Economics.
Their children, Annabelle and Antoni, are contribut-
ing significantly to the promotion of good health.
Annabelle is a graduate of Vassar College. She
earned a Master of Arts degree in Medical Social
Work from the University of Minnesota, then pur-
sued this profession for several years. Her husband,
Dr. R. P. Bush, is an outstanding psychiatrist. An-
toni is an assistant professor of Pediatrics at the Uni-
versity of Kansas Medical School. He has a special
research and clinical interest in rheumatic fever and
cardiology. His wife, Sybil, is a graduate of the
Peter Bent Brigham School of Nursing. The Diehls
also are proud of their 7 grandchildren.

Special tribute must be paid to Dr. Diehl’s wife,
Julia. It is doubtful whether any woman ever con-
tributed more importantly to her husband’s success.
She kept constantly informed on the details of his
work, promoted good will from their home to all
members of the faculty and their families, and was
ever ready to participate in anv and every activit\
to advance the welfare of the School of Medicine.
On the occasion of the presentation of liis portrait.
Dr. Diehl said, “First of all I want to acknowledge
the credit that rightly belongs to Mrs. Diehl. For
thirty years she has not only made a splendid home
for our family but also has helped, encouraged, and
supported me in my work. She has been superb,
not only as a companion but also as your dean’s
wife.”

311

JULY 1958

WORK WITH THE STUDENT HEALTH SERVICE

The Student Health Service at the University of
Minnesota was first organized in 1917 under the
direction of Dr. John Sundwall. Four vears later,
when Dr. Sundwall accepted a position at the Uni-
versity of Michigan, Dr. Diehl took over the director-
ship of this infant organization. His superior admin-
istrative ability was immediately in evidence, and
the Student Health Service soon ranked among the
best of such organizations. In addition to a large
full-time medical, nursing, and clerical staff, he had
every important specialty in medicine represented
by part-time physicians who were in private prac-
tice. An arrangement was also made whereby mem-
bers of the University Hospital staff were available
for consultation and special procedures including
surgery. Uppermost in his mind always was the best
possible medical care for the student body.

Dr. Diehl was one of the moving spirits in organ-
izing the American Student Health Association, now
known as The American College Health Association.
In this organization, he was active in promoting
formation of Student Health Services in various col-
leges and universities throughout the country. He
was president of the organization from 1927 to
1929. He also participated in organization of re-
gional health service associations and presided over
the North Central Association in 1932.

While directing the Student Health Service, Dr.
Diehl constantly conducted research and encouraged
and promoted such activities by his staff members.

TUBERCULOSIS CONTROL WORK

He also initiated and promoted some of the most
important tuberculosis control work in this country.
The first student health service tuberculosis clinic
was established in the University of Minnesota.

His keen interest in tuberculosis had been estab-
lished early in his school days. When he was a
freshman, his anatomy dissecting partner died from
tuberculous meningitis, and, throughout the remain-
der of his medical course, he saw other students drop
out of school because of this disease. Therefore,
when the opportunity came, he struck tuberculosis
with all of his might. From 1921 to 1927, he ob-
served the cases found among students, a prepon-
derance of whom were in the schools of nursing and
medicine. He promoted the administration of the
tuberculin test to all students entering the Univer-
sity in 1928. This revealed that only 33 per cent
were infected instead of 100 per cent as was gen-
erally believed and taught. Moreover, all the clinical
cases were derived from that 33 per cent.

In 1929, he arranged to examine two classes from
the schools of medicine, nursing, and education each
year they were in school. This included the usual
physical examination, the tuberculin test, and flu-
oroscopic and roentgen film inspection of the chest.
From the beginning, this study was most revealing.
He immediately began working on plans for making
chest x-ray film inspection of all students who re-
acted to the tuberculin test on admission. This was

accomplished in the fall of 1931. So much clinical
tuberculosis was found that the test became a per-
manent part of students’ entrance examination.

In 1932, Doctor Diehl said, “It should be possible
bv extending such a program to the entire student
body or to any other group of individuals to diag-
nose all tuberculosis in its truly curable stage and
to prevent individuals in the group from transmit-
ting the infection to their associates.”

The 1929 study provided a unique opportunity
for research in tuberculosis. Periodic examination of
students infected before entering the school elim-
inated those who already had clinical disease on
admission and found those in whom such disease
evolved while they were in school. This prevented
tuberculous students from infecting others.

Periodic testing with tuberculin of the uninfected
provided information as to the interval between
exposure to contagious cases and the development
of sensitivity of tissue as well as the appearance of
demonstrable lesions with reference to prevalence
and nature of lesions. Knowing that when students
became reactors to tuberculin thev had been in con-
tact with persons who had contagious disease, the
sources of their infections were sought.

This study demonstrated that numerous persons
who were being admitted to general hospitals with
various authentic diagnoses also had coexisting, con-
tagious, and frequently unsuspected tuberculosis.

No sooner had Dr. Diehl become dean of Med-
ical Sciences in 1935 than he attacked this problem.
The first step consisted of administering the tuber-
culin test to all patients admitted to the University
Hospital and making x-ray film inspections of the
chests of the reactors. So many cases of clinical tu-
berculosis were found bv this admission examination
that it soon was adopted as a routine procedure.
Today it is employed by the hospitals in Minneapolis
and St. Paul and administered to 80 per cent of all
persons being admitted to Minnesota hospitals. Its
value has been so thoroughly proved that this pro-
cedure is now recognized bv hospitals everywhere.

The second step was the examination of all hos-
pital personnel with tuberculin and making x-rav
films of the chests of the reactors. This revealed con-
tagious cases in persons, such as librarians, maids,
and orderlies, in such numbers as to require pre-
employment examination and subsequent semiannual
examinations.

In order to further protect students of nursing and
medicine, rigid contagious disease technic was de-
veloped and employed wherever and whenever tu-
berculous patients were in the hospital. This technic
has also been adopted by all general hospitals in this
area. Students were warned against working with
cases of tuberculosis in the absence of such technic.

The effectiveness of this program rapidly became
evident, first in a precipitous decrease in the infec-
tion attack rate among students who had entered
school uninfected as well as in morbidity and mor-
tality rates. For example, among the students grad-
uating from the School of Medicine in the classes of

312

THE JOURNAL-LANCET

1919 to 1932, it was found that 92 had developed
demonstrable tuberculosis and 1 1 had died. Where-
as, in the classes graduating from 1943 to 1957,
only one student of medicine had a lesion evolve to
x-ray shadow-casting proportion.

Of Dr. Diehl’s numerous accomplishments, prob-
ably none will be responsible for the prevention of
more invalidism and more untimely death than the
fundamental method he developed for protecting
students of nursing and medicine and other hos-
pital personnel from tuberculosis. His method is
applicable to everv hospital, every school of nursing,
and everv school of medicine in the world.

RESEARCH WITH THE COMMON COLD

Dr. Diehl is widely known for extensive research on
the common cold, conducted throughout most of the
years he directed the Student Health Service. His
interest in this problem has continued, and his nu-
merous writings on the subject are authoritative.

INAUGURATION OF COLLEGE BUILDING PROGKAM

When he became dean of Medical Sciences, he in-
augurated a building program for the college which,
over a period of twenty years, has doubled the phys-
ical facilities of the school. In addition, he has pro-
vided staff and equipment for his school so that it
is now regarded as one of the finest medical institu-
tions in the world.

Bv 1957, Dr. Diehl had made final plans for a
new medical-biological library on the Medical School
campus, and the Masonic Cancer Hospital was under
construction. Plans were being completed for the
Clinical Cancer Research Institute provided by Vet-
erans of Foreign Wars, for greatly expanded research
laboratories, for an additional story for the Heart
Hospital, and for complete remodeling of Millard
Hall and Jackson Hall — two of the original buildings
on the medical campus. All of this was bringing to
culmination what- he considers an adequate medical
center for care of patients, teaching, and investiga-
tion.

CONTRIBUTIONS TO NATIONAL MILITARY
AND HEALTH AFFAIRS

In addition to service in World War I, Dr. Diehl
later contributed significantly to military and health
affairs of this nation. He was a member of the Na-
tional Advisory Health Council from 1937 to 1941.
This council is advisory to the surgeon general of the
United States Public Health Service on policies and
programs of the service. From 1940 to 1941, he was
a member of a committee on medical education of
the Office of Emergency Management in Washing-
ton. This committee arranged for the program of
deferment of medical and premedical students and
medical faculty members during the period of mili-
tary drafts and prior to the start of World War II.

From 1941 to 1946, he was a member of the di-
recting board of the Procurement and Assignment
Service of the War Manpower Commission and was
chairman of the Committee on Allocation of Health

Personnel. This board, with Dr. Frank Leahy as
chairman, was responsible tor formulating policies
and making plans of operation to assure the best
possible distribution of health personnel to meet
military and civilian needs. The Committee on Allo-
cation, of which Dr. Diehl was chairman, prepared
the actual data for staffing medical schools, health
departments, wartime industrial establishments, and
civilian practice as well as the military services.

From 1950 to 1957, he was vice chairman of the
Health Resources Advisory Committee of the Office
of Defense Mobilization. This committee made plans
and outlined policies for the most effective utiliza-
tion of the health resources of the nation in case of
national emergency. It organized the national blood
program and the stockpiling of medical and health
supplies and passed upon requests of all military
departments for the withdrawal of physicians, den-
tists, and nurses from civilian practice for military
service.

During this time, he was also vice chairman of
the Medical Advisory Committee of the National
Headquarters of Selective Service. This committee,
operating through state and local committees, rec-
ommends to Selective Service upon the availability
of individual physicians, dentists, and nurses who
are liable for military service.

He played a prominent role in the reorganization
of the medical services of Veterans Administration
Hospitals, with provision for affiliation of these hos-
pitals with medical schools. In fact, the affiliation
between the University of Minnesota Medical School
and the Minneapolis Veterans Administration Hospi-
tal was a pilot experiment in this program and served
as an example or model for the extension of the pro-
gram throughout the country.

Dr. Diehl devoted a tremendous amount of time
to these various national organizations. For example,
the National Advisory Council of the United States
Public Health Service met once or twice a year. The
Directive Board of the Procurement and Assignment
Service met once or twice a month, and the Health
Resources Advisory Committee and the National
Advisorv Committee of the Selective Service met
twice a month from 1950 to 1955 and once a month
from 1955 to 1957.

From 1946 to 1952, he was a member of the Ad-
visory Board on Health Service of National Ameri-
can Red Cross. He has served as honorary consult-
ant to the surgeon general of the United States Navy
since 1955. He also served on the Medical Advisory
Panel of the United States Office of Vocational Re-
habilitation. He was a member of the United States
Delegation to the World Health Assembly in Geneva
in 1954 and in Mexico City in 1955.

For many years, he has been a fellow of the
American Public Health Association and was a mem-
ber of the Governing Council from 1946 to 1950.
He is a fellow of the American Medical Association
and was chairman of the section of Preventive In-
dustrial Medicine and Public Health from 1938 to
1940. He has been a member of the American Med-

JULY 1958

313

ioal Association Council on National Defense since
its establishment in 1950 and chairman since 1955.
He is Chairman of the Committee on Medical Edu-
cation and Hospitals, Minnesota State Medical Asso-
ciation. He has long been a member of the boards
ot his county and state tuberculosis associations. In
1956 and 1957, he was vice-president of the Asso-
ciation of American Med ieal Colleges.

Dr. Diehl holds membership in many other or-
ganizations including the Central Society for Clin-
ical Research, the American Association for Ad-
vancement of Science, the Minnesota Academy of
Science, the Minnesota Academy ot Medicine, the
Minnesota Societv of Internal Medicine, and the
Minnesota Public Health Conference and Phi Delta
Theta, Nu Sigma Nu, Phi Beta Kappa, Alpha Omega
Alpha, and Sigma Xi fraternities.

LITERARY ACCOMPLISHMENTS

It is unfortunate when a physician who has oppor-
tunities to make contributions to medical knowledge
does not record them in medical literature. The med-
ical world is fortunate in that Dr. Diehl has recorded
in medical journals and books his numerous obser-
vations on methods, procedures, and results ob-
tained. There is no substitute for experience. With
approximately forty years of experience as a phy-
sician, Dr. Diehl has spoken and written with ever
increasing authority. Careful perusal of the bibli-
ography of approximately 200 references included
in this sketch provides an insight of the tremendous
volume of work he has done and informs readers of
the phases of medicine in which he has worked most.

Many physicians who write do so only for med-
ical readers. In addition to such laudable writing,
Dr. Diehl has always envisioned the importance of
transmitting health information to the public. His
long and broad experience admirably qualified him
for writing the book, Healthful Living, published in
1935. This book is dedicated “To those who prefer
facts to fads, sanity to superstition, understanding to
belief. The sixth edition is now in preparation. This
has become a textbook in personal hygiene in many
colleges and universities throughout America. Thus,
the broad and long experience of one who has con-
tributed so much to the welfare of humanity is be-
ing passed on to thousands of students who, in turn,
are disseminating it among their contacts to the end
that the common desires of mankind everywhere —
to live long, happily, and efficiently, ever contribut-
ing to the good of the world — will he achieved.

PRAISE OF ASSOCIATES AND FRIENDS

On October 8, 1951, the Medical School faculty
presented the University with a portrait ot Dr. Diehl,
which has been placed permanently in the faculty
room of the Mayo Memorial Building. In making the
presentation, Dr. E. T. Bell, emeritus professor of
pathology, concluded “It is a tribute to the best med-
ical dean Minnesota has ever had, and, even more
importantly, it is a token to Harold and Julia of our
deep affection. President Morrill closed his accept-

ance remarks as follows, “Dean Diehl has brought
leadership of the highest order to the College ol
Medical Sciences and thereby to the University.

“On behalf of the Regents, I am delighted to
receive. Dean Diehl, from your colleagues this
manifest and living memorial of your devotion and
achievement.

A few of Dr. Diehl’s close associates have kindh
contributed to this sketch by the following brief per-
sonal evaluations of his life and work:

Dean Diehl’s distinguished administrative leadership
in medical education and research has been a massive
building stone in the structure of the University of Min-
nesota.

With patient and productive persistence, he has
brought the College of Medical Sciences at our Univer-
sity to acknowledged eminence among the great medical
centers of the nation and the world. Witli rare insight
he has appraised the capacities and recruited the serv-
ices of a group of medical scientists, teachers, and re-
searchers whose high competence is universally acknowl-
edged and has given them encouragement and support
to assure their splendid accomplishments.

In the development of medical school physical fac-
ulties and equipment through public and private assist-
ance, his efforts have been notably sustained and re-
warded— these are a monument to his industry and de-
votion.

In the long history of the University, Dean Diehl’s ca-
reer will shine as a beacon of strength and integrity
and example.

J. L. Morrill, President
University of Minnesota

For a friend to write an appraisal of a friend is, in
a sense, a strange deed. Did I hold Harold Diehl as a
friend in spite of serious faults, I would write nothing.
In actuality, space limits my words hut not my sincerity.
As my father and my uncle before me, I hold deep re-
spect and admiration for the abilities, accomplishments,
and loyalty of Harold Diehl. The high and enviable place
that the Medical School of the University of Minnesota
holds is due in great measure to his efforts. Minnesota
is much richer for his having been a resident here and
having been Dean of our Medical School.

To his wife and to him, long life, health and happi-
ness in continuing service to others.

Charles W. Mayo
Mayo Clinic

To one who has had the privilege of working closely
with Harold Diehl over many years, there are three
characteristics which stand out above all others — first, his
unique ability to select young men and women of prom-
ise; second, his unusual capacity to provide opportunities
for these staff members to develop their full potentiali-
ties; and third, his warmth and friendliness.

Always generous with encouragement, enthusiastically
interested in new ideas, patient and understanding ol
personal problems ol his staff, lie lias aided and guided
the development of many outstanding physicians and
medical scientists.

This interest in able young people plus the rare ability
to generate an atmosphere ot friendliness and coopera-
tion among the stall are significant reasons win the Uni-
versity Health Sendee and Medical School became out-
standing under his leadership.

Ruth E. Boynton, M.D.

Director, University Health Service

314

THE JOURNAL-LANCET

I have worked for and with Harold Diehl since our
days together in Base Hospital 26 in World War I. I was
his assistant when he was first appointed pathologist of
the University Hospitals in 1920. We then went together
as director and assistant director, respectively, of the
Student Health Service and thence to the newly organ-
ized Department of Preventive Medicine and Public
Health. Since I left Minnesota, our paths have crossed
many times on various committee and organizational
assignments, notably, in and out of Washington. I did
this work for and with Harold Diehl because I liked to.
One never felt that he was working for Dr. Diehl but
rather with him, and I have often pondered why this
was so. He has an administrative genius which is as ef-
fective as it is difficult to analyze. Like myself, I sus-
pect that many of his faculty members at Minnesota
were totally unaware of the quiet and effective manner
in which he guided us and in which he fulfilled the pri-
mary function of an administrator, that is, to set up a
work environment for each of us which would develop
our maximum capacities. Few realize how hard and
persistently he worked toward this objective. The amaz-
ing growth and present eminence of the Medical School
is a testimonial to this genius.

For one thing, Harold Diehl always knew what he was
talking about when addressing himself to an administra-
tive problem. You might be certain that he had given it
many hours of thoughtful study and analysis, and, to do
this, he frequently burned the midnight oil. I have seen
him do the same thing in his committee work in Wash-
ington so that almost imperceptibly but automatically he
became the best informed member of the committee on
a problem to which he addressed himself. Having
reached a conclusion as to the best course of action,
he had an uncanny ability to discern the right people to
lead in the solution of the problem. He has never been
anything but kindly, presenting his arguments calmly
and in natural sequence and upholding the worthy ob-
jective which he sought so that clashes in personality and
even in political belief melted away in the interest of
attaining that objective. Lastly, I never knew Harold
Diehl to criticize anyone. That is perhaps the main rea-
son we all like to work with and for him.

W*. P. Shepard

Metropolitan Life Insurance Company

As Harold Diehl’s brother-in-law, I prefer to devote
my few lines to some personal comments as to his genius
in another direction — namely, in selecting members of
his family. He chose for his father a delightful, cultured
gentleman of the cloth, a Lutheran minister, who for
many years was in charge simultaneously of three
churches in the rural part of western Maryland. He re-
ceived no salary worth mentioning, but, in spite of that,
all four of his children had a rich life and all graduated
from college. The Reverend William Kleinfelter Diehl
came from a Pennsylvania Dutch family which received
its land grant directly from William Penn.

Harold showed equally good judgment in the selec-
tion of his mother, a brilliant woman of Scotch-Irish de-
scent, from a distinguished family of educators from Get-
tysburg, Pennsylvania. Mrs. Diehl, sometimes affection-
ately referred to by her children as “Mrs. Preacher” was
the organist for the three churches.

He deserves additional credit for having selected two
fine younger brothers. One of them, Norman, is a pur-
chasing agent for the DuPont Company in Wilmington,
Delaware, and the other, William, is an educator assist-
ing in supervising the school system in Washington
County, Maryland.

Still more to his credit, he arranged to have the
youngest of the four children be a girl, Anna, who is a
graduate of the University of Minnesota School of Nurs-
ing and makes an admirable wife and mother.

Those of us here in New York City have difficulty in
feeling too sorry for the Minnesotans who have lost
Harold and Julia because we are so pleased to have them
join the host of Minnesota immigrants in this metropolis.
New York is the richer for this transfer.

J ames E. Perkins, Managing Director
National Tuberculosis Association

Having been associated with Dr. Diehl since about
1922, I have come to know and respect him for many
reasons. As an employer, he treated one like an associate,
and, also, as an employer, he treated one as a good
friend.

Julia and Harold were interested in me personally and
in my family. They watched our progress from the time
of our marriage, the birth of the children, the children’s
education and marriage, and the onset of quite a few
grandchildren.

I would like to say that some of his greatest assets
were his ability to judge professional capacity and re-
late that to the personality. These were important in
building up a smooth working medical school. Friction
in the staff of the University of Minnesota Medical School
was at a minimum.

Due to his sense of values, he built a balance among
the departments, keeping in mind his responsibility to
the undergraduate and the necessity for training physi-
cians for practice in Minnesota as well as preparing phy-
sicians for the specialties.

He had a great interest in the paramedical field.
Through his effort, courses in Physical Therapy, Occupa-
tional Therapy, Practical Nursing, X-Ray Technic, and
the like were established. There is no measuring how
great an influence this has been on hospital and medical
care in the state.

Among his attributes are his patience and his judgment
in letting time solve problems that harass people. In
many instances which I can think of, some reactions
would not have been nearly as productive as letting time
solve the problem.

Certainly, as a man and a friend, his leaving Minne-
sota has left a big hole in my heart.

Ray Amberc, Director
University of Minnesota Hospitals

To few men has it been given to accomplish so much
in the field of education in the medical sciences as was
achieved by Harold Diehl during his service as dean.
Coming to his task with a background of outstanding
accomplishment in the development of the Student
Health Service, lie guided the expansion and growth of
the College of Medical Sciences in a manner that earned
for him well deserved local, national, and international
recognition and respect. With a clear understanding of
the needs and ideals of medical education at both under-
graduate and graduate levels, he strengthened that which
was old and helped to pioneer that which was new. A
deep appreciation for public health found expression in
the creation of a school of public health with a broad
program of professional and lay education intimately
allied with other facets of education in the health sci-
ences. His recognition of the importance of ancillary
services in over-all medical care was expressed through
the support he has given to the strengthening and de-
velopment of these fields. Above all, Harold Diehl has
been far more than a respected leader. As we who have

315

JULY 1958

worked most closely with him reflect upon our associa-
tions, we appreciate the loyal support, the understanding
guidance, and the sympathetic friendship that have
earned for him such a host of devoted and loyal friends
in all fields that have felt the warmth of his personal
touch.

Gaylord W. Anderson, M.D.

Director, School of Public Health,

University of Minnesota

Probably no one on the faculty of the School of
Medicine to which Dr. Diehl has devoted his pro-
fessional life has known him as long or is more ap-
preciative of and takes greater pride in his accom-
plishments than I. When he entered the School of
Medicine in 1914, I was instructor and taught his
section in anatomy. His sincerity, truthfulness, hon-
esty, forthrightness, and fine scholarship were con-
stantly impressed upon me throughout that school
year. When he became director of the Student
Health Service seven years later and during the next
fourteen years, he supported mv chest clinic to the
greatest degree. As chief of the Department of Pre-
ventive Medicine and Public Health in 1923, he
nominated me for a position in his department for
the teaching of public health and epidemiologic as-
pects of diseases of the chest with particular refer-
ence to tuberculosis. All through the years that he
continued to head that department and direct the
Student Health Service, he was an ideal chief, always
encouraging and supporting teaching and research.
This continued in the same steadfast manner after
he became dean of Medical Sciences in 1935 and
has been abiding.

Early in the forty-four years of our close associa-
tion, one of the main reasons for Dr. Diehl’s superb
success as an administrator unfolded. When he was
a student of anatomy, he never presented dissection
demonstrations until he had worked out every detail

PUBLICATIONS OF

1. The effect of high pressures on bacteria (with W. P. Lar-
son and T. B. Hartzell). J. Infect. Dis. 22:271, 1918.

2. The specificity of bacterial proteolytic enzymes and their for-
mation. J. Infect. Dis. 24:347, 1919.

3. Spontaneous rupture of the spleen following a carbuncle.
J.A.M.A. 82:951, 1924.

4. Students' health service at the University of Minnesota.
Minnesota Med. 7:271, 1924.

5. The part of the practicing physician in public health work.
Minnesota Med. 5:671, 1922.'

6. A scarlet fever epidemic in an agricultural school (with W.
P. Shepard). J.A.M.A. 79:2079, 1922.

7. Part time physicians in student health work. Journal-Lancet
44:446, 1924.

8. Relations of student’s health service of the university to the
physicians of the state. Journal-Lancet 44:446, 1924.

9. Rural and urban health. A comparison of physical defects in
university students from rural and urban districts (with W.
P. Shepard). J.A.M.A. 83:1117, 1924.

10. Mental hygiene studies of university freshmen (with A. W.
Morrison). J.A.M.A. 83:1666, 1924.

11. The prevention of athletic injuries. The Coach 1: No. 4.
1924.

12. Uniform records for health services. Proc. Am. Student
Health A., 1925.

13. Rural and urban health. II. A comparison of past diseases in
university students from rural and urban districts (with W.
P. Shepard). J. Indust. Hyg. 7:481, 1925.

14. Systolic blood pressures in young men. Arch. Int. Med. 36:
151, 1925.

15. Value of chlorine in the treatment of colds. J.A.M.A. 84:
1629, 1925.

and had the subject well in hand. When he directed
the large staff of the Student Health Service; the
teaching of faculty members of a department in the
School of Medicine; and, finally, the Medical Sci-
ences, when the Medical School alone had more than
600 faculty members; and, at the same time, direct-
ed a huge building program and participated in
committee meetings in Washington and elsewhere
two dozen or more times a year, many trying and
difficult problems were before him for final solution.
All through life, the traits that probably stood him
in best stead were those which were so well in evi-
dence when he was a student of anatomy; namely,
calmness and an ability to assemble all facts, ana-
lyze them carefully, and arrive at correct and just
decisions. In controversies between staff members
and the like, he exhibited almost unbelievable pa-
tience. When serious situations confronted him, he
often said, “Patience and time solve many problems.”

Speaking for the faculty of the School of Medi-
cine, Dr. E. T. Bell said, “He has welded us together
as a friendly cooperative group. It is a joy to all
of us to congratulate him on his long, successful
career.”

In 1957, Dr. Diehl accepted the positions of sen-
ior vice-president for Research and Medical Affairs
and deputy executive vice-president of the American
Cancer Society. A spokesman of the Cancer Society
said, “We are extremely fortunate in obtaining Dr.
Diehl’s great talent and rich experience.” Thus, he
continues to serve in an important health field.

When it was announced that Dr. Diehl was leav-
ing, the faculties of the College of Medical Sciences
were unanimous in the statement of President f. L.
Morrill, “The University must regard his ultimate
departure with deepest regret, vet with heartiest con-
gratulations and pride.”

HAROLD S. DIEHL

16. Colds and their treatment with chlorine. Minnesota Med.
8:445, 1925.

17. A health program for a state parent-teacher association.
Northwest Health J. 11:20, 1926.

18. Results of the Schick test at the University of Minnesota.
Minnesota Med. 9:9, 1926.

19. Organization of Students’ Health Service at the University
of Minnesota. Proc. Am. Student Health Assoc. No. 10,

1926.

20. Preventive medicine in the student health service. J. Pre-
ventive Med. l:No. 5, 1927.

21. Acute respiratory infections among motormen and conductors
(with M. C. Harrington and D. D. Turnacliff). 1.
Indust. Hyg. 9:5, 1927.

22. Periodic health examinations. Proc. Minnesota State Con-
ference & Institute Social Work, pp. 94-106, September,

1927.

23. Research opportunities in student health work. Proc. Am.
Student Health A. No. 11:68, 1927.

24. Periodic health examination of medical students. Bull. Assoc.
Am. Med. Coll. 3:144, 1928.

25. Student health and mental hygiene. Educational Rec.
(supp. ), 1928.

26. Control of student health, in Problems of College Education.
Minneapolis: University of Minnesota Press. 1928, p. 327.

27. A health examination record form for purposes of follow-up
and research. Proc. Am. Student Health A. 12:67, 1928.

28. Health and scholastic attainment. U.S. Public Health Rep.
44:41, 1929.

29. Health examinations for college students. Hygiea 8:51, 1930.

30. Blood pressure variability: morning and evening studies.

Arch. Int. Med. 43:835, 1929.

316

THE JOURNAL-LANCET

31. Blood pressure variability: a study of systolic pressure at five
minute intervals. Arch. Int. Med. 44:229, 1929.

32. The physique of smokers as compared to non-smokers: a

study of university freshmen. Minnesota Med. 12:424, 1929.

33. Students’ Health Service at the University of Minnesota.
State Board of Control Quart. 29:2, 1929.

34. Evolution of student health work, in Students’ Health Serv-
ice Dedication. Minneapolis: University of Minnesota Press.
1929, p. 21.

35. Racial differences in blood pressure. Minnesota Med. 14:
726, 1931.

36. Wassermann reactions in college students. Am. J. Pub.
Health 21:1131, 1931.

37. Advantages and disadvantages of combining health service
with physical education and athletics in one administrative
unit. Proc. Am. Student Health A. No. 15:140, 1931.

38. Albuminuria in college men (with C. A. McKinlay). Arch.
Int. Med. 49:45, 1932.

39. Tuberculosis control in University of Minnesota. Journal-
Lancet 52:224, 1932.

40. The Duluth casual labor group (with A. H. Hansen and
M. R. Thabue). Employment Stabilization Research Insti-
tute Series, Vol. 1, No. 5. Minneapolis: University of Min-
nesota Press, 1932, 34 pages.

41. Personnel Study of Duluth Policemen (with D. G. Pater-
son, B. J. Dvorak, and H. P. Longstaff). Employment
Stabilization Research Institute Series, Vol. 2, No. 2. Min-
neapolis: University of Minnesota Press, 1933, 16 pages.

42. Health service at the University of Minnesota works to ad-
vantage of physicians as well as students. Western Hosp.
Rev. 20:23, 1932.

43. A health service hospital for university students. Mod. Hosp.
40:78, 1933.

44. Revision of 1925 Manual of Suggestions for the Conduct of
Periodic Examinations of Apparently Healthy Persons. Chi-
cago: Press of American Medical Association, 1933, 55 pages.

45. Heights and weights of American college men. Human Biol.
5:445, 1933.

46. Heights and weights of American college women. Human
Biol. 5:600, 1933.

47. Changes in blood pressure of young men over a seven-year
period (with M. B. Hesdorffer). Arch. Int. Med. 52:948,

1933.

48. Syphilis — an individual health problem. Journal-Lancet 53:
345, 1933.

49. Amebic dysentery and food handlers. Journal-Lancet 54:39,

1934.

50. Medicinal treatment of the common cold. J.A.M.A. 101:
2042, 1933.

51. The student nurse and tuberculosis (with T- A. Myers and
H. D. Lees). J.A.M.A. 102:2086, 1934.

52. Physical Findings among Certain Groups of Workers (with
H. D. Rempel and D. G. Paterson). Employment Stabili-
zation Research Institute Bulletin, Vol. 3, No. 7. Minne-
apolis: University of Minnesota Press, 1934, 23 pages.

53. Public health in Minnesota (with A. J. Chesley, O. Mc-
Daniel, H. A. Whittaker, and E. C. Hartley), in Report
of the Committee of Public Health of the Minnesota State
Planning Board. Part II. (Mimeo. ), 1934, p. 1.

54. Albuminuria in young men (with C. A. McKinlay), in The
Kidney in Health and Disease. Philadelphia: Lea and Febi-
ger, 1935, p. 453.

55. The evolution of tuberculosis in students of nursing and
medicine (with J. A. Myers, H. D. Lees, and Ida Levine),
in Transactions of the Thirtieth Annual Meeting of the Na-
tional Tuberculosis Association, 1934, p. 345.

56. The relation of college health services to the private prac-
tice of medicine. Proc. Am. Student Health A., 1933; Jour-
nal-Lancet 54:294, 1934.

57. The health of college students. Journal-Lancet 54:664, 1934.

58. The common cold among college students. Tournal-Lancet
54:723, 1934.

59. The common cold. New York J. Med. 35:109, 1935.

60. Treatment of the common cold. J. Indust. Hyg. 17:48, 1935.

61. Physical efficiency tests. J.A.M.A. 104:265, 1935.

62. Healthful Living. Whittlesey House Health Series. New
York: McGraw-Hill Book Company, 1935, 352 pages.

63. Illness among student nurses. Am. J. Nursing 35:11, 1935.

64. Relationship between physical condition and unemployment.
U.S. Public Health Rep.' 50: 1610, 1935.

65. Exercise tolerance tests. J.A.M.A. 105:305, 1935.

66. Scarlet fever immunization during a school epidemic ( with
R. G. Hinckley). J.A.M.A. 106:1354, 1936.

67. Venereal diseases in college students. Journal-Lancet 56:
295, 1936.

68. Tuberculosis in college students (with J. A. Myers), in
Transactions of the Thirty-second Annual Meeting of the Na-
tional Tuberculosis Association, New Orleans, 1936, p. 163.

69. Physical superiority of college students. Hygiea 14:799, 1936.

70. Studies of the treatment of colds. Journal-Lancet 56:533,

1936.

71. Dean Lyon and the University of Minnesota Medical School.
Minnesota Med. 19:791, 1936.

72. The development of tuberculosis in adult life (with J. A.
Myers, Ruth E. Boynton, and B. Trach). Arch. Int. Med.
59:1, 1937.

73. Periodic health examination, in Practitioners Library of
Medicine and Surgery, Vol. 12. New York: P. Appleton-
Century Co., 1937, p. 3.

74. The relative value of fluoroscopic, roentgenographic and
physical examinations in a tuberculosis case-finding program
in university students (with Ruth E. Boynton and C. E.
Shepard). Am. Rev. Tuberc. 37:49, 1938.

75. Development of tuberculosis in adult life (with J. A. Myers,
Ruth E. Boynton, and B. Track). Arch. Int. Med. 59:1,

1937.

76. The Minnesota comprehensive examination plan. J. A. Am.
Med. Coll. 13:71, 1938.

77. Training of public health personnel for the Midwest, in Pro-
ceedings of the Conference on Facilities for Training of
Public Health Personnel. United States Public Health Serv-
ice, 1938, p. 95.

78. Tuberculosis in medical and nursing hospital personnel (with

I. A. Myers, Ruth E. Boynton, and B. Trach). Ann. Int.
Med. 11:2181, 1938.

79. A Textbook of Healthful Living. New York: McGraw-Hill
Book Co., Inc., 1939, 634 pages.

80. The Health of College Students (with C. E. Shepard). A
report of the American Youth Commission. Washington,
D. C.: American Council on Education, 1939, 169 pages.

81. The common cold, in How to Live. New York: Funk and
Wagnalls, 1938, p. 323.

82. The significance of the student health movement, in Uni-
versity of Michigan Health Service, Twenty-fifth Anniversary.
Ann Arbor: University of Michigan Press, 1939, p. 16.

83. Cold vaccines; an evaluation based on a controlled study
(with A. B. Baker and D. W. Cowan). J.A.M.A. Ill:
1168, 1938.

84. The fiftieth anniversary of the founding of the Medical
School. Med. School Digest 2:137, 1939.

85. The Medical School in retrospect and prospect. Minnesota
Alumni 39:289, 1940.

86. Tuberculosis prevention, immunization and periodic health
examinations among medical students (with I. A. Myers).

J. A. Am. Med. Coll. 15:104, 1940.

87. Tuberculosis in hospital personnel. J.A.M.A. 114:102, 1940.

88. Zoology for pre-medical students. Science 89:604, 1939.

89. American medicine and the war. Minneapolis Star-Journal,
January 12, 1940.

90. Medical careers in public health. J.A.M.A. 115:343, 1940;
Diplomate 13:121, 1941.

91. Cold vaccines — a further evaluation (with A. B. Baker
and D. W. Cowan). J.A.M.A. 115:393, 1940.

92. Tuberculosis among students and graduates in nursing (with
J. A. Myers, R. E. Boynton, P. T. Y. Ch’iu, and T. L.
Streukens). Ann. Int. Med. 14:873, 1940.

93. Tuberculosis among students and graduates in medicine
(with J. A. Myers, R. E. Boynton, P. T. Y. Ch’iu, T. L.
Streukens, and B. Trach). Ann. Int. Med. 14:1575, 1941.

94. Chester Arthur Stewart (editorial), Journal-Lancet 61:240,
1941.

95. Stop killing yourself. Hygiea 19:168, 1941.

96. Discussions of Postgraduate Medical Education. J. A. Am.
Med. Coll. 16:151, 1941.

97. The Physician in Selective Service. J.A.M.A. 116:1724,
1941.

98. Health services and medical care for college and university
communities, in Haven Emerson, Administrative Medicine,
vol. 7. New York: Thomas Nelson and Sons, 1942, 22 pages.

99. The University of Minnesota Medical School. Bull. Minne-
sota Med. Foundation 3:17, 1941.

100. Medical officers of the future. Minnesota Med. 24:1055,

1941.

101. The prehabilitation of selective service registrants (with
Ruth E. Boynton). J.A.M.A. 117:623, 1941.

102. Report of Committee on Awards. Am. Med. Assoc. Daily
Bull. 39:1, 1942.

103. What medical, dental, and nursing schools may do to hasten
the graduation of their respective students. J. A. Am. Med.
Coll. 17:32, 1942.

104. Discussions of interns and their health. J.A.M.A. 117:1125,

1942.

105. Role of medical education in the war. J.A.M.A. 17:369, 1942.

106. What the procurement and assignment service means. Dallas
M. J. 28:84, 1942.

107. Medicine and the war — restatement of duties of the various
units of the procurement and assignment service. J.A.M.A.
119:800, 1942.

JULY 1958

317

108. Medicine and the war — questions and answers on procure-
ment and assignment service. J.A.M.A. 119:888, 1942.

109. Medical education during the war — procurement and assign-
ment service. J.A.M.A. 119:1262, 1942.

110. Vitamins for prevention of colds (with D. W. Cowan and
A. B. Baker). J.A.M.A. 120:1268, 1942.

111. The common cold. Proc. Inter-State Postgrad. Med. Assoc.
October 26-30, 1942, pp. 252-58.

112. Elements of Healthful Living. New York: McGraw-Hill

Book Co., Inc., 1942.

113. Procurement and assignment service and medical education
(with Margaret D. West). J. A. Am. Med. Coll. 18:15,
1943.

114. Tuberculosis among students and graduates of schools of law
and medicine (with I. A. Myers, R. E. Boynton, and T. L.
Streukens). Yale J. Biol. & Med. 15:439, 1943.

115. Medical education and the procurement and assignment serv-
ice. J.A.M.A. 121:635, 1943; Diplomate 15:159, 1943.

116. Dental education and the procurement and assignment serv-
ice. J. Dental Education 4:322, 1943.

117. The procurement and assignment service for physicians, den-
tists, and veterinarians — responsibilities, accomplishments,
and future problems. Bull. Am. Coll. Surgeons 2:170, 1943.

118. Healthful Living for Nurses (with Ruth E. Boynton). New
York: McGraw-Hill Book Co., Inc., 1944, 534 pages.

119. Cures for the common cold. Am. Mercury 57:478, 1943.

120. Medical education after the war. Ann. Am. Acad. Political
& Social Sc. 231:88, 1944.

121. Problems of postwar medical education. J.A.M.A. 124:819,
1944; Minnesota Med. 27:314. 1944.

122. Relationship of procurement and assignment service and
state medical associations. J.A.M.A. 124:100, 1944.

123. The procurement and assignment service — current policies:
Part of symposium on medical education and the war.
J.A.M.A. 122:1093, 1944.

124. Discussion of papers by Drs. W. C. Rappleye, Victor John-
son, and J. T. Wearn on postwar medical education, effects
of the accelerated program of medical schools, and declining
standards of medical teaching. T. A. Am. Med. Coll. 19:
87, 1944.

125. Gifts for medical research. Minnesota Med. 27:302, 1944.

126. Intranasal vaccine for the prevention of colds (with Donald
W. Cowan). Ann. Otol. Rhin. & Laryng. 53:286, 1944.

127. The doctor’s service — at home, in industry, and at war, in
Doctors at War. New York: E. P. Dutton and Co., Inc.,
1945, p. 59.

128. Report of Committee on Hospitals and Medical Education.
Minnesota Med. 27:752, 1944.

129. Seventy-five years of medical journalism in the Northwest.
Journal-Lancet 65:82, 1945.

130. The Mayo Memorial. Journal-Lancet 65:84, 1945.

131. Discussion of papers on Medical and Graduate Medical Ed-
ucation in Postwar Period. J.A.M.A. 127:107, 1945.

132. Seventy-five years of medical journalism in the Northwest.
Journal-Lancet 65:82, 1945.

133. The new medical care plan for veterans, in American Bro-
chure, 1946, p. 1.

134. The Mayo memorial. Minnesota Med. 28:581, 1945.

135. Discussion of paper on Graduate Record Examination as an
Aid in the Selection of Medical Students. J. A. Am. Med.
Coll. 21:145, 1946.

136. The common cold, in Americana Annual, 1946, 1948, 1949,
1951, 1952.

137. Report of the Committee on Medical Education and Hospi-
tals, Minnesota State Medical Association. Minnesota Med.
29:16, 1946.

138. Medical education and medical practice. Minnesota Med.
29:920, 1946.

139. The common cold, in Diseases of the Chest. Springfield,
Illinois: C. C Thomas, 1948, p. 403.

140. The common cold. Encyclopedia Britannica, 1948.

141. Doctor William A. O’Brien. Journal-Lancet 67:454, 1947.

142. Prevention of tuberculosis among students of nursing (with
R. E. Boynton and J. A. Myers). Am. J. Nursing 47:661,
1947; Everybody’s Health, 33:4, 1948.

143. Robert G. Green. Minnesota Med. 31:299, 1948.

144. Cold prevention study. Influenza vaccine for the prevention
of the common cold (with D. W. Cowan). Minnesota Med.
31:504, 1948.

145. Round table discussion on residency programs in veterans
hospitals (with E. H. Cushing, T. R. Harrison, P. B. Mac-
nuson, J. R. Miller, and B. O. Raulston). J.A.M.A. 133:
856, 1947.

146. Prevention of tuberculosis among students of medicine (with
R. E. Boynton, Susanna Geist-Black, and J. A. Myers).
J.A.M.A. 138:8, 1948; Diplomate 20:229, 1948.

147. Antihistaminic agents and ascorbic acid in the early treat-
ment of the common cold (with Donald W. Cowan).
J.A.M.A. 5:421, 1950.

148. Plans of medical students for practice (with Myron M.
Weaver). Minnesota Med. 33:446, 1950.

149. Personal Health and Community Hygiene (with R. E.
Boynton). New York: McGraw-Hill Book Co., Inc., 1951.

150 .Policy on deferment of hospital residents during 1951.
J.A.M.A. 145:837, 1951.

151. British medical education and the national health service
(with L. R. Chandler and S. E. Dorst). J.A.M.A. 143:
1492, 1950.

152. A medical school for the University of Missouri; report to the
Board of Curators. J. Missouri M. A. 48:203, 1951.

153. Physicians for rural areas, a factor in their procurement.
J.A.M.A. 145:1134, 1951.

154. Medical school faculties in the national emergency (with
Margaret D. West and Robert W. Barclay). J. Med.
Education 27:233, 1952.

155. The University’s College of Medical Sciences. Minnesota
Med. 35:46, i952.

156. Staffing patterns at four-year medical schools (with M. D.
West and R. W. Barclay). 1. Med. Education 27:309,

1952.

157. Physical fitness of priority I physicians under public law
779 (with M. D. West and P. K. Koetzel). J.A.M.A. 151:
161, 1953.

158. Medical schools and medical education over the past cen-
tury. Minnesota Med. 36:332, 1953.

159. Medical research at Minnesota. Minnesota Alumni 52:10,

1953.

160. How the medical school serves the state. Minnesota Alumni
53:13, 1953.

161. Staffing patterns at four-year medical schools (with M. D.
West and R. W. Barclay), in Medical Education Today.
Chicago 1953, p. 34.

162. Panel discussion: Continuing impact of the national defense
program on medical education. Proc. Annual Congress on
Medical Education and Licensure, A.M.A. 153:31, 1953.

163. Professional education in public health. Pub. Health Re-
ports 68:890, 1953.

164. The work week of physicians in private practice (with H.
A. Rusk, R. W. Barclay, and P K. Kaetzel). New Eng-
land J. Med. 249:678, 1953.

165. Health and Safety For You (with A. D. Laton). New York:
McGraw-Hill Book Co., Inc., 1955, 515 pages.

166. Alien physicians training in hospitals in the United States
(with E. L. Crosby and P. K. Kaetzel). J.A.M.A. 156:1,

1954.

167. Tuberculosis in physicians (with J. A. Myers, R. E. Boyn-
ton, and H. L. Horns). J.A.M.A. 158:1, 1955.

168. The truth about common colds. This Week Magazine, Nov.
14, 1954, p. 16.

169. Elian Potter Lvon, medical educator of vision. Minnesota
Med. 37:501, 1954.

170. Mayo memorial dedicated. Minnesota Med. 37:780, 1954.

171. Short courses in medical technology. Minnesota Med. 37:
592, 1954.

172. World health assembly. Minnesota Med. 37:671, 1954.

173. 1955 legislative request. Minnesota Med. 38:50, 1955.

174. Distinguished scientists join faculty. Minnesota Med. 38:
121, 1955.

175. Lhidergraduate education for general practice. Minnesota
Med. 38:201, 1955.

176. Tuberculosis in physicians (with J. A. Myers, R. E. Boyn-
ton, and H. L. Horns). J.A.M.A. 158:1, 1955.

177. The family physician. Minnesota Med. 38:442, 1955.

178. The eighth world health assembly: malaria eradication. Sci-
ence 122:126, 1955.

179. The physical and world medicine (with L. W. Larson and
F. D. Murphey). J.A.M.A. 158:1147, 1955.

180. Tuberculosis among nurses (with J. A. Myers and R. E.
Boynton). Dis. Chest 28:611, 1955.

181. Minnesota graduates in public health work. Minnesota Med.
38:947, 1955.

182. Wanted — more applicants for medical school. Minnesota
Med. 39:51, 1956 .

183. Education for general practice. Minnesota Med. 39:185,
1956.

184. Health as an instrument of international policv. J.A.M.A.
161:1371, 1956.

185. A thirty-six year study of diseases of the chest on a univer-
sity campus (with J. A. Myers and R. E. Boynton). Jour-
nal-Lancet 77:117, 1957.

186. Tuberculosis among university students; a thirty-five year ex-
perience (with J. A. Myers and R. E. Boynton). Ann. Int.
Med. 46:201, 1957.

187. Hospital house staffs, 1950-55 (with E. L. Crosby and
R. K. Kaetzel ) . J.A.M.A. 164:273, 1957.

188. Doctor draft substitutes. Hearing before Committee on
Armed Services. U.S. Senate, on H.R. 6548. Government
Printing Office, p. 32, 1957.

318

THE JOURNAL-LANCET

Carroll E. Palmer

Merits World-Wide Recognition

J. ARTHUR MYERS, M.D.

Minneapolis, Minnesota

Physicians and their allies of the Upper Mid-
west take particular pride in the high honor re-
cently bestowed upon Dr. Carroll E. Palmer bv the
Roval College of Physicians in London, England.

Dr. Palmer was born at Fairmont, Minnesota, in
1903. He received the degree of Bachelor of Science
from Hamline University, St. Paul, in 1925; Master
of Arts in 1927, Doctor of Medicine in 1928, and
Doctor of Philosophy in 1929 from the University
of Minnesota. He was associate in biostatistics at
Johns Hopkins School of Hygiene and Public Health
from 1929 to 1936 and consultant in child hygiene
in the United States Public Health Service from 1932
to 1936. He was statistician and supervisor of med-
ical records at Johns Hopkins Hospital in 1935 and
1936. He was director of research in the Child Hy-
giene Office, United States Public Health Service
from 1936 to 1942. Since that time, he has directed
the research of the Tuberculosis Program of the Di-
vision of Special Health Services. He has been a
medical director in the Commissioned Corps of the
United States Public Health Service since July 1950.
He is a diplomate of the American Board of Pre-
ventive Medicine and Public Health and is founder
of and holds membership in numerous local, national,
and international medical and public health organi-
zations.

In 1945, Dr. Palmer published a medical classic
in which he showed for the first time that histoplas-
mosis is a prevalent condition in certain parts of the
United States. Prior to this study, the disease had
been thought to be universally fatal. Since this ini-
tial work, the histoplasmin test has become a routine
diagnostic procedure in many places and its role in
the differential diagnosis of fungous infections has
been greatly clarified. Since 1945, he has continued
to do extensive work in histoplasmosis and other
fungous diseases and has made valuable contribu-
tions to knowledge in that field.

Among other researches in this country, Dr. Palmer
has directed a ten-year study of tuberculosis in stu-
dent nurses and 4 trials of BCG vaccination in ( 1 )
children in Puerto Rico, (2) American Indian chil-
dren, (3) inmates of institutions for the mentally ill,
and (4) a general population in Muscogee County,
Georgia, and Russell County, Alabama. More recent
work under his direction includes cooperative thera-
peutic trials of the use of the newer antituberculosis
drugs and extensive studies on the prophylactic use
of isoniazid in tuberculosis control.

From 1949 to 1955, Dr. Palmer served, in addi-
tion to his duties for the Public Health Service, as
chief of the Tuberculosis Research Office of the
World Health Organization, with headquarters in
Copenhagen, Denmark. During that time, he or-
ganized a field research program which demonstrat-
ed that precise, scientific epidemiologic research can
be done on a world-wide basis. Results of the work
of the Tuberculosis Research Office have served as
a guide to the practical tuberculosis work of WHO
and have greatly influenced local tuberculosis serv-
ices in many parts of the world.

All of this and more has afforded Dr. Palmer the
best position of anv world citizen to evaluate the
tuberculosis control measures throughout the world
over the past ten years and to emphasize the pro-
cedures necessary to eradicate the disease (see his
paper in the June issue of The Journal-Lancet).

Dr. Palmer was the second American physician to
receive the Weber-Parkes Prize in London, Dr. Eu-
gene Opie being the first in 1945. This award is
bestowed only once each three years and was given
Dr. Palmer for his contribution in interpreting tu-
berculin sensitivity and his work in tuberculosis im-
munization. He is the author of more than 100
articles published in medical and public health jour-
nals and has work in progress which promises many
more excellent contributions to knowledge.

JULY 1958

319

JCancet

CLINICAL

REVIEWS

This department of The Journal-Lancet is devoted to reports on
cases in which all the appropriate diagnostic criteria have been
employed, the best known treatment administered and the residts
recorded. It is desired that these case reports be so prepared that
they may be read icith profit by physicians in general practice,
hospital residents and interns and may be of considerable value to
junior and senior students of medicine. This department welcomes
such reports from individuals or groups of physicians who have
statable cases which they desire to present.

Female Pseudohermaphrodism

A Case Report

JOHN F. BRIGGS, M.D., and
JAMES BELLOMO, M.D.

St. Paul, Minnesota

On March 22, 1936, J. M. was born at Ancker
Hospital, St. Paul. Her mother’s pregnancy
was normal. The delivery was normal. A phys-
ical examination at the time of discharge from
the hospital revealed a normal white female in-
fant. Except for an attack of bronchial pneumo-
nia in August 1938, no untoward events were
noticed in the child’s development. In October
of 1939, the mother reported that she was in-
secure about the child’s sex. She had noticed
that the external genitalia had now changed in
appearance and that they did not “look” like a
girl's “genitalia.” The patient was readmitted to
the hospital on October 2, 1939. The physical
examination at this time was normal except for
the genitalia. The examination of the pelvis re-
vealed no masses in the abdomen nor were any
masses present in the groin, the perineum, or the
labia. The clitoris was enlarged and resembled a
penis. At the base of the clitoris was an opening
near its surface which led into what appeared
to be a vaginal sac. The labia had the appear-
ance of a scrotum; on separation of the labia, the
skin between covered the vaginal entrance. The
urethra led back into this pouch. No urethra
could be found in the clitoris.

On October 18, 1939, bismuth paste was in-
jected into the external urinary meatus. This re-

john f. briggs is associate professor of clinical medi-
cine at the University of Minnesota, james bellomo
is a St. Paul internist.

vealed a long tract corresponding to the urethra,
but it also connected with the vagina. The vag-
inal chamber appeared normal. The urethral
canal extended anteriorly and superiorly to the
vagina and entered the bladder space. The in-
travenous urogram showed that the bladder was
normal in size, lying superiorly and anteriorly
to the vagina, and the dve outlined the urethra
in the canal to the vagina. On October 24, 1939,
a laparotomy was performed. The uterus was
found to be extremelv small and felt like a ridge
at the junction of the tubes with the uterus.
The tubes themselves seemed normal in size.
The uterus resembled a fibrous cord. No fundus
was visible, and it had the appearance of a bi-
cornate uterus. The gonads were in normal po-
sition and relationship to the fimbriated end of
the tubes. A biopsy from the medial portion of
each gonad was taken. There were no abnor-
malities in the pelvis. The biopsy revealed nor-
mal ovarian tissue. Since the sex of the patient
was definitely established, on November 4, 1939,
a director was inserted into the urogenital sinus.
Using this as a guide, the urogenital sinus was
opened and the incision carried posteriorly until
the urethra and vagina were completelv exposed.
The mucous membrane was then sutured to the
skin, and a temporary pack was left in the va-
gina. Dilatation of the vagina was carried out
periodically by the mother. There was no evi-
dence of breast development, very scanty growth
of pubic hair, and a mild degree of hirsutism

320

THE JOURNAL-LANCET

had appeared. On July 2, 1944, the patient en-
tered St. Joseph’s Hospital for further study. At
this time, air injections of the perirenal areas
were normal. The glucose tolerance test and
blood cholesterol tests were normal. On August
12, 1944, the clitoris, which had now developed
into a structure comparable to the male penis of
the corresponding age, was amputated. At 9
years of age, the patient had a very definite
beard and axillary hair. Pubic hair was now
present. At 10 years of age, breast development
appeared for the first time in the areola and the
nipple became enlarged, but there was no evi-
dence of breast tissue itself . On May 13, 1954,
the patient entered St. Joseph’s Hospital for fur-
ther study. At this time, she was 60 in. tall,
weighed 101 lb., and the physical examination
was completely normal with the following ex-
ceptions: (1) the presence of a facial beard,

(2) male type of pubic hair, (3) very little
axillary hair, (4) complete absence of any breast
tissue, and (5) no sign of ovulation. At this time,
the laboratory examinations all were normal, and
the 17-ketosteroid test was normal. A mass was
felt in the abdomen which suggested an ovarian
cyst. On June 11, 1954, an abdominal laparotomy
was performed, and the left tube and ovary were
removed. The ovary was cystic, and the histo-
logic diagnosis was serous, papillary cystadeno-
ma of the left ovary. The tube was normal, and
the appendix was removed routinely. On ex-
ploration of the abdomen, the right tube and
ovary were found to be normal, and the uterus
appeared normal in size, shape, and position.

On September 3, 1954, a sufficient amount of
Hvdrocortone was obtained to treat the patient.
Under steroid treatment starting on September
3, 1954, the size of the patient’s breasts began
to increase and became painful and swollen.
The hirsutism disappeared, and the patient be-
gan to have very definite spotting. Bv February
of 1955. she had been having a one-day monthly
period. The Hvdrocortone was decreased gradu-
ally and finallv discontinued entirely. With ces-

sation of the Hydrocortone, the monthly spotting
continued. At times, the flow lasted four days,
and, at other times, merely spotting or a one-day
discharge occurred.

On April 22, 1955, her breasts were large, her
face was now hairless, and she looked like a
girl. The vagina was essentially normal in size
following the repeated dilatation, and the clit-
oris, which had been partially amputated, was
now about the size of a normal clitoris.

The patient married. In February of 1957, she
had a spotting period, and then, on April 2,
1957, reported that she had missed her March
period completely. Examination revealed that
the breasts were large, firm, and painful and
that the uterus seemed enlarged to the size of
a six weeks’ pregnancy. There was no further
growth in uterine size. A frog test was nega-
tive, and a rabbit test was negative. On April
23, 1957, the same physical findings were pres-
ent. On April 30, 1957, the patient reported that
she had had a very heavy flow of blood lasting
six days. This was unusual in that the amount
of flow was more than usual, and clots were
present. The examination now revealed that the
breasts had returned to normal size and that the
uterus, which was normal in size, could be pal-
pated. It was our feeling that the patient had
become pregnant and that when seen by us she
was suffering from a missed abortion. She is
perfectly well and is still menstruating.

CONCLUSION

A case is reported of a female pseudohermaph-
rodite who has been studied since birth. Recon-
struction of the vagina has resulted in a normal
vaginal passage. The use of steroids has oblit-
erated the hirsutism and brought about a normal
menstrual period, and we believe that she was
pregnant in February 1957 but aborted sponta-
neously. Tbe patient is still menstruating and
has the appearance of a perfectly normal woman.

Hvdrocortone supplied through the courtesy of Merck &
Co., Inc.

JULY 1958

321

Section on PAIN

Foreword

The distress associated with dysmenorrhea may he communicated to society indi-
vidually and collectively, and this subject is described in broad terms in the paper
entitled, “Primary Dysmenorrhea: Current Concepts and Treatment,” by Dr.

Martin L. Stone and Dr. Alvin F. Goldfarb. This excellent review of the whole
subject should be of general interest to all.

John S. Lundy, M.D.

Primary Dysmenorrhea:

Current Concepts and Treatment

MARTIN L. STONE, M.D., and
ALVIN F. GOLDFARB, M.D.

New York Gitv

Primary dysmenorrhea, that is, menstrual
pain for which no concomitant organic cause
can be found, presents a real challenge to the
conscientious physician. It is fairly widespread,
having been estimated to occur in about 35 per
cent of menstruating women.1 This same inci-
dence has been noted in surveys of high school
and college girls.2 The disorder causes consid-
erable interference with normal routines in many
cases. For example, 20 per cent of a group of
392 high school girls were reported to have
missed classes 1 or more times during the aca-
demic year because of dysmenorrhea, and 5 per
cent missed school 4 to 8 times. The economic
loss to the individual and to industry is said
to be 3 times as great as from the common cold.3

Although dysmenorrhea has been recognized
and treated since the dawn of medical history,3
the cause in most cases remains obscure. The
varying responses to treatment in different indi-
viduals, and the observation that many unrelated
tvpes of therapy produce good results in a sig-
nificant percentage of cases, lead one to believe
that different mechanisms may be at work in dif-
ferent individuals.

martin l. stone is professor and director of the De-
partment of Obstetrics and Gynecology at New York
Medical College, Flower and Fifth Avenue Hospi-
tals. New York City, alvin f. c.oldfarb is clinical
instructor and chief of the Gynecology and Endo-
crinology Clinic.

PSYCHIC FACTORS

The psychic element has been given an enor-
mous amount of emphasis by those interested
in this aspect of the subject. Among the psy-
chologic factors which have been suggested are
lack of proper preparation for menstruation; “old
wives' tales;” sexual taboos; improper attitudes
on the part of the mother, such as oversolicitous-
ness and considering the menstrual period as a
time to be unwell; unwillingness to face adult
life; and the beginning of social relationships
with boys. The psychic element must not be
overlooked, especially since a failure of adapta-
tion of this magnitude in adolescence often au-
gurs similar failures in the adjustments of adult
life — as in marriage, pregnancy, and child-rear-
ing. If the young person is helped early with
understanding and positive guidance, these mal-
adjustments arising later in life may often be
prevented.

On the other hand, the importance of avoid-
ing undue emphasis on the psychosomatic as-
pects of dysmenorrhea is shown in an interest-
ing study by S chuck.4 He compared the health
records of 300 dysmenorrheic students with 300
whose menstrual periods were “normal.” There
was no more indication of psychoneurosis, that
is, the characteristic multiplicity of complaints,
in the former than in the latter. In fact, more
than 60 per cent of the students in the affected
group listed menstrual pain as the only disturb-
ance.

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Section on PAIN

POSSIBLE PHYSIOLOGIC CAUSES

In a small percentage of cases of dysmenorrhea,
an organic cause is found on careful examina-
tion, such as endometriosis, dermoid cyst, or
pelvic inflammation. The dysmenorrhea in such
cases is designated as “secondary” and will not
be considered here.

Various alterations in physiologic balances
have been proposed by workers in the field.
Sehuck4 attempted to establish a state of in-
creased autonomic spasticity as a cause in his
cases, thinking that a “vagotonic” constitution
might play a role. He was unable to correlate
the dysmenorrheic condition with other mani-
festations of parasympathetic overactivity, such
as history of gastrointestinal disturbances, asth-
ma, hay fever, and nervousness. Conversely,
“vagotonic” patients did not have an unusual
incidence of dysmenorrhea. Medications, such
as atropine or belladonna, which have a specific
effect on parasympathetic spasms were found to
have no beneficial effect on menstrual pain. In
addition, the theory that the cramps are reac-
tions to mechanical obstruction that must be
overcome by painful muscular contractions had
to be discarded because no correlation could
be shown between the onset of pain and of free
menstrual flowing. Thus, pain might occur hours
or days before, concomitantly with, or several
hours after the onset of flow.

A factor which does fit the above timetable of
the onset of pain, however, is the vasoconstriction
or angiospasm of the endometrial arteries, which
starts from five to twenty-four hours before the
bleeding, continues during the establishment of
flow, and is later characterized by alternating
vasoconstriction and vasodilation. Vasodilators
were found to have a variable effect on pain,
producing good relief in some cases and none
in others. The good effect of estrogen in a high
percentage of cases is postulated as being due
to a vasodilating factor contained in or activated
by the estrogenic hormone.4

The tlieorv of arterial vasoconstriction is also
put forth by Parsons3 in bis discussion of the
possible mechanism of dysmenorrhea. He men-
tions the vasoeonstrieting effect of progesterone
as opposed to the vasodilating effect of estrogen.
The relative lack of progesterone in anovulatory
cycles may help to explain the painlessness of
these periods. A combination of factors, such
as increased uterine tonicity in the presence of
uterine ischemia, may serve to explain the lack
of response to therapy directed at a single cause.

Some other factors which have been consid-

ered important in the past but which are now
believed to be operative in only occasional cases
are: narrowing of the cervix, underdevelopment
of the uterus, and the action of a menotoxin as
postulated by Smith and Smith. Since the latter
believe that this substance is produced by all
menstruating women in the catabolic stage of
the cycle,5 it is difficult to explain the occur-
rence of dysmenorrhea in only a minority.

TREATMENT

Treatment of dysmenorrhea should be preceded
by a thorough physical examination and detailed
history. A vaginal examination is not necessary
or even desirable in young girls; a rectal exam-
ination should suffice. The history should include
an inquiry into the patient’s attitude toward
menstruation and her degree of knowledge about
this function and the process of maturing. On
the basis of these data, the physician should
supply any additional information or correct any
misinformation that seems indicated. Often a
sympathetic attitude toward the young person’s
story and a little encouragement and advice do
a great deal to improve the condition in mild
cases. Proper diet, regular hours, and general
hygiene should be stressed. A.P.C., Edrisal, and
other standard analgesic preparations are widely
recommended in this type of case. Stretching
exercises, as described bv several workers,6-8
have brought relief in a high percentage of cases
after two or three months. Crossen5 has de-
scribed and illustrated the technic for perform-
ing these exercises.

Hormone therapy. In more severe cases, not
adequately helped by the preceding measures,
a more specific plan of therapy is needed. Usu-
ally, this means administration of one or another
of the hormones. Progesterone has had a cer-
tain popularity in the past on the theory that
it has a quieting effect on the uterus, but results
have not, on the whole, been sufficiently encour-
aging to warrant its continued use.3-4 Testos-
terone, given in the first half of the cycle, has
been attended by some success; most investi-
gators believe this to be due to suppression of
ovulation. A dose large enough to suppress ovu-
lation is also apt to cause masculinizing phe-
nomena, and, thus, the risk seems to outweigh
the advantages. Thyroid extract is often benefi-
cial where specifically indicated, most often in
patients living in areas of endemic hypothyroid-
ism.

Estrogen seems to be the hormone of choice
in the therapy of severe dysmenorrhea.3 Selmck,4

JULY 1958

323

however, found it ineffective in 40 per cent of
cases. Although the efficacv of estrogen has been

O J o

attributed to suppression of ovulation, Schuck
found that it exerted the anticipated beneficial
effect in many cases in which it was demon-
strated that ovulation had occurred in spite of
therapy.

Various forms of estrogen may be used. Be-
ginning on the first day of the cycle or as soon
as oral medication can he tolerated, 1 mg. of
diethylstilbestrol, 0.05 mg. of ethinyl estradiol,
or 1.25 mg. of a conjugated estrogen preparation,
such as Premarin, is given. Daily doses are given
at bedtime for twenty days and then discontin-
ued. Painless withdrawal bleeding should begin
about six days after discontinuation. Therapy is
resumed with the onset of bleeding and the regi-
men repeated for three months, after which all
therapy is withdrawn to allow the patient to
ovulate normally and to assess the degree of
permanent relief. Another very successful regi-
men is 5 mg. of diethylstilbestrol taken for six
nights before the estimated time of ovulation.5’
In spite of the beneficial results, ovulation is not
always suppressed. If no relief occurs in the
first period after therapy is initiated, subsequent
courses will usually be ineffective also.

The combined use of estrogen and testosterone
in the preovulatory phase has recently been used
with excellent results.9 A tablet containing con-
jugated estrogens, 1.25 mg. of Premarin, and 10
mg. of methyltestosterone is given three times
daily from the seventh to the fourteenth days of
the cycle. This usually produces a painless cycle
the first month, and, after two painless cycles,
dosage can be reduced until an optimum dose
is obtained. The side effects of either hormone
are greatly reduced by the combined therapy.

Heald and associates10 prefer not to use ex-
tensive estrogen therapy in adolescents for fear
of disturbing the adjustment of hormonal pat-
terns at this time. However, it may be valuable
to use one course to produce a pain-free period,
which will indicate the absence of organic pa-
thology, demonstrate to a skeptical patient the
physiologic nature of her ailment, and encourage
confidence in the physician.10

Antispasinodics. Amphetamine, which appar-
ently has a uterine spasmolytic effect as well as
mood-elevating action, is often prescribed with
analgesics in dysmenorrhea. Atropine, belladon-
na, and phenobarbital have been advocated,3 but
Schuck’s opinion that the atropine-like drugs
seldom are beneficial has been noted. They may
relieve colicky pains in some cases, hut backache

and bearing-down pains are seldom helped. In
spite of the fact that recent opinion seems to
minimize the role of uterine spasm in dysmen-
orrhea, reports of success with some of the newer
or even certain older antispasinodics continue to
appear. This seems to substantiate the idea that
a combination of vasoconstriction and uterine
spasm is at work in many cases of menstrual
pain.

For example, Jones11 has reported good re-
sults with the use of a new drug, lututrin, de-
rived from the corpus luteum of sows’ ovaries
and standardized for potency in terms of units
of activity on the guinea pig uterus. It has been
found to have a potent relaxant effect on uterine
contractions, even stopping those produced by
Pituitrin. In 40 cases of dysmenorrhea, Jones
obtained better results than he had previously
had with any other type of treatment. Complete
symptomatic relief occurred in 57.5 per cent, and
cramps were sufficiently improved in 30 per cent
to enable the patients to go about their duties.

Malkin12 treated dysmenorrhea with methan-
theline (Ban thine), a quaternary ammonium com-
pound known to be useful in alleviating visceral
spasms in peptic ulcer, biliary colic, ureteral
spasm, and so forth. Though the series of pa-
tients was small, results were encouraging in that
gastrointestinal symptoms disappeared, uterine
pain was well controlled or disappeared en-
tirely, and abdominal bloating decreased. Dos-
age was 25 to 50 mg. orally three times a day
after meals, starting two or three days before
the expected onset of menses and continuing
through the first day of flow. Malkin believes
that methantheline may promote vasodilatation
through its sympathetic blocking effect as well
as relax the uterine musculature and diminish
uterine contractions through its parasympathetic
blocking effect. “Hence the integrated effect
would be a smaller contraction in the presence
of an increased vascular supply and therefore
less pain.”

Magnesium gluconate, a newer magnesium
preparation said to be better tolerated than the
older forms, has been used in eclampsia and dvs-
menorrhea for its known depressant and anti-
spasmodic actions on neuromuscular functions.
It has been found to have a powerful spasmo-
lytic action on the tetanized pig uterus. Raw-
lings13 used an aqueous magnesium gluconate
solution (1.3 gm. in M oz. of water) orally for
seven days, beginning four days before the
menses and continuing for the first three days
of the period. For premenstrual pain, treatment

324

THE JOURNAL-LANCET

fMMWkl

was started seven days before menses and con-
tinued through the first day. Of 15 women com-
plaining of premenstrual pain, 5 were relieved
and continued pain-free tor a six- to twelve-
month follow-up period; 8 obtained relief, but
relapsed when therapy was discontinued; and
2 failed to respond. Of 18 women with men-
strual pain, 5 appeared cured, 11 obtained tem-
porary relief, and 2 failed to respond. Little
corroborative evidence of the usefulness of this
therapy has appeared.

Vasodilators. Long before uterine ischemia
with arteriolar vasocontriction was postulated
as one of the causes of dysmenorrhea, alcohol,
known as a vasodilator, was used empirically by
physician and layman alike to alleviate cramps
and backache. Caffeine, an ingredient of many
proprietary preparations, may also aid relief
through its vasodilating action. Aminophylline
has produced good results in one study,14 though
its effect was attributed to its spasmolytic action
on uterine muscle rather than to vasodilatation.
Recently, various drugs with specific and potent
vasodilating effects have been tried in dysrnen-
orrhea with varying degrees of success.

Butler and McKnight15 carried out careful
trials with vitamin E because of its well-known
beneficial effect on vasospasm, for example, in
Buerger’s disease. The study included 100 stu-
dents with dysmenorrhea who were otherwise in
good health and seemed to have no psychologic
difficulties. Of these, 50 received vitamin E tab-
lets ( 50 mg. ) three times a day, and 50 received
placebos. These were given out by the students’
supervisor ten days before the period was due.
The tablets and placebo were given in strict ro-
tation, and the investigators did not know which
girls received the vitamin E. In general, results
were considered sufficiently encouraging to war-
rant further clinical trials: for example, of 28
girls who were incapacitated during the menses
before therapy, 7 were symptom-free at the sec-
ond month after therapy, 8 had only discomfort,
' 7 had slight pain but were not incapacitated, and
6 showed no change. In the over-all picture, 34
of the 50 treated, 68 per cent, showed some im-
provement compared with 9 of 50 controls, 18
per cent. Parsons3 has also advocated vitamin E
in dysmenorrhea for its effect on the vascular
i bed.

Another vitamin with vasodilating properties,
niacin, has been reported to produce excellent
relief of dysmenorrhea in 90 per cent of cases,
especially when given in conjunction with rutin
and ascorbic acid.16 These vitamins are believed

to potentiate the vasodilating effect of niacin
through their ability to decrease capillary per-
meability. The therapy is considered partly phar-
macodynamic (vasodilating action) and partly
nutritional, inasmuch as the improvement often
lasts for several months after treatment is discon-
tinued. The preparation used contained 100 mg.
niacin, 60 mg. rutin, and 300 mg. ascorbic acid.
It was given night and morning for at least seven
to ten days before the onset of How and every
two to three hours during the usual period of
pain.

Schuck4 experimented with Padutin, a vasodi-
lative, insulin-free hormone from the pancreatic
gland, in a series of 80 cases. The drug caused
no side effects and produced fair to good pain
relief in about 50 per cent of patients. Over-all
results were not as good as those produced with
estrogenic hormones. He notes that Priscoline,
a far stronger synthetic vasodilator, has been
used by others with correspondingly better re-
sults, but uncomfortable and even severe side
effects are common.

Antihistamine preparations. Antiallergic ther-
apy, consisting of antihistaminic drugs or epi-
nephrine, has been used with some success in
dysmenorrhea. Whether this success is due to
correction of some allergic factor in a given case
or to an antispasmodic effect of the antihista-
mines is not known. Macpherson17 atributes his
spectacular success with epinephrine in one very
severe case and his subsequent good results with
this drug or an antihistamine in other cases to
correction of a “pelvic allergy ” in which the
pelvis presents much the same condition as the
chest in asthma. Maietta18 used an antihista-
mine preparation with good results in 20 patients
with severe dysmenorrhea, all but 1 of whom
had a personal, and, in some cases, a family his-
tory of allergy, such as asthma, hay fever, or
eczema. All of the patients experienced excel-
lent control of symptoms; placebos given in place
of the antihistamine were strikingly ineffective.

Miscellaneous drugs. Rauwolfia has been tried
in dysmenorrhea with little or no benefit.3 Chlor-
promazine, alone or in combination with Edri-
sal, has produced excellent results in severe cases
which had not responded to bed rest and anal-
gesic or sedative therapy.19 The drug was first
compared with A.P.C. and a placebo in a double-
blind study involving 48 patients. All three medi-
cations were effective, but ehlorpromazine was
the most effective in patients with nausea, vom-
iting, and a great deal of tension and anxiety
accompanying the dysmenorrhea. In a second

JULY 1958

325

Section oh PAI N

part of the study, chlorpromazine plus Edrisal
and codeine sulfate plus Edrisal were compared.
The proportion of good responses was almost
identical. Thus, in dysmenorrhea severe enough
to give rise to vomiting or to require narcotics,
chlorpromazine appears to be a useful adjunct
to other medications and a substitute for co-
deine.

Two proteolytic enzymes, papain and brome-
lain, the former produced from green papaya
fruit and the latter from juice of the stems of
mature pineapple plants, have very recently
shown some promise in dysmenorrhea.20 While
being tested for their efficacy as contrast media
in hysterography, it was noted that in addition to
their mucolytic effect, which clears the passages
and facilitates better roentgenograms, these sub-
stances greatly relaxed and dilated the cervical
canal. It was decided to try these enzymes in
primary dysmenorrhea. Various solutions were
injected directly into the uterus when painful
cramps began and were retained for five minutes.
Of 64 patients treated in this manner, 40 experi-
enced immediate relief which was maintained
for the duration of the flow and sometimes for
more than one period. Those who failed to re-
spond were later found to have secondary dys-
menorrhea. Thus, the procedure was not only
therapeutic but diagnostic. Though this may be
a valid procedure in some cases in which other
methods short of surgery have failed, the incon-
venience and the likelihood of embarrassing the
average patient would not commend it for rou-
tine use. The procedure also would not be suit-
able for adolescents.

Surgical procedures. It is generally agreed
that all forms of therapy should be tried in in-
capacitating dysmenorrhea before resorting to
major surgery, such as presacral neurectomy. A
minor surgical procedure, which may be carried
out in severe cases, is dilatation of the cervix
and curettage.310 The reason for its beneficial
effect in some cases is not clear. Benefit has been
attributed to the damaging of nerve endings in
the plexus around the external os by forceful
dilatation of the cervix. It may be that the curet-
tage, which removes all the endometrium and
provides a clean base for the hormones to act
on, is the more important factor. Be that as it
may, satisfactory results are obtained in about
50 per cent of cases.3 Heald and associates10
state that the improvement is seldom permanent,
however.

Presacral neurectomy should be performed
only in patients in whom menstrual pain is of

uterine origin; ovarian dysmenorrhea does not
respond.3,21 In addition, this procedure will be
successful only in patients in whom suppression
of ovulation by hormone therapy has been shown
to produce a pain-free period. If pain is not re-
lieved and it can be demonstrated that ovulation
has actually been suppressed, the patient either
has unrecognized pelvic disease or is a candi-
date for psychotherapy.3 After careful screening,
between 5 and 10 per cent of patients with dys-
menorrhea will be suitable subjects for presacral
neurectomy. Black21 performed the operation in
70 cases of primary and acquired dysmenorrhea
and reported a long-term follow-up in 61 of these
patients. Complete relief was obtained in 62 per
cent of 45 primary cases and partial relief in
29 per cent; complete relief occurred in 75 per
cent of 16 acquired cases and partial relief in
19 per cent. Most of those partially relieved
felt that the operation was worthwhile. Black
describes the technic in some detail.

Doyle22 calls attention to the limitations of
presacral neurectomy, which include the facts
that the usual percentage of success is only 60
to 70 per cent, backache or dull pelvic aching
is seldom helped, ovarian dysmenorrhea is not
responsive, and menometrorrhagia is usually ag-
gravated. He presents the procedure of transec-
tion of the cervical plexus as a more physiologic
and successful technic. He found it particularly
valuable in patients with acquired dysmenorrhea
who are often not helped by presacral neurec-
tomy. Relief of this type of dysmenorrhea oc-
curred in 94.5 per cent of his patients, and 86.3
per cent were complctehj relieved. This is higher
than the percentage of success usually attributed
to presacral neurectomy. Associated menomet-
rorrhagia was relieved. Symptoms did not tend
to recur as sometimes happens after the other
operation. The technic is described and illus-
trated.

SUMMARY

Current concepts of the pathogenesis and treat-
ment of primary dysmenorrhea have been re-
viewed. The treatment of this condition is ex-
tremely complex because of the difficultv of
ascertaining a clear-cut cause for the syndrome
in most cases. However, a high percentage of
patients may be helped by one or a combination
of methods reviewed here if the individual pa-
tient’s total personality and physical make-up
are considered and every clue is followed which
may aid in linking the dysmenorrhea to some
characteristic physiologic pattern. For example.

326

THE JOURNAL-LANCET

Section on PAIN

the allergic patient’s dysmenorrhea may have
an allergic basis «... the underdeveloped pa-
tient’s trouble nitty be of endocrine origin . . .
the “vagotonic” type may be relieved by anti-

spasmodics . . . and so on. With such an ap-
proach, it should be unnecessary for these un-
fortunate persons to go from physician to phy-
sician seeking help.

REFERENCES

1. Tones, H. E.: Office treatment of gynecological disorders,

j. Tennessee M. A. 45:221, 1952.

2. Gallagher, J. R.: Dysmenorrhea and menorrhagia in ado-

lescence. Connecticut M. J. 19:469, 1955.

3. Parsons, L.: Symposium on specific methods of treatment;

dysmenorrhea, its causes and treatment. M. Clin. North
America 38:1419, 1954.

4. Schuck, F.: Pain and pain relief in essential dysmenorrhea.
Am. J. Obst. & Gynec. 62:559, 1951.

5. Crossen, R. J.: Diseases of Women, ed. 10. St. Louis: C.
V. Moshy Co., 1953, p. 837.

6. Clow, A. E. S.: Treatment of dysmenorrhea bv exercise.

Brit. M. J. 1:4, 1932.

7. Billig, H. E., Jr.: Dysmenorrhea; result of postural defect.

Arch. Surg. 46:611, 1943.

8. Haman, J. O.: Pain threshold in dysmenorrhea. Am. J. Obst.
& Gynec. 47:686, 1944.

9. Ibarra, J. D., Jr., and Higginbotham, W. H.: Symposium

on endocrine disorders and endocrine therapy; endocrine ther-
apy of amenorrhea, dysfunctional uterine bleeding, and dys-
menorrhea. M. Clin. North America 39:1189, 1955.

10. Heald, F. P., Jr., and others: Dysmenorrhea in adolescence.
Pediatrics 20:121, 1957.

11. Jones, S. S.: Lututrin: new drug for relief of dysmenorrhea.
Northwest Med. 54:1253, 1955.

12. Malkin, S.: Use of Banthine in primary dysmenorrhea.

Canad. M. A. J. 73:214, 1955.

13. Rawlings, W. J.: Magnesium in dysmenorrhoea. M. J. Aus-
tralia 1:61, 1949.

14. Anderson, H. E., and McIntyre, A. R.: Use of aminophyl-
line in primary dysmenorrhea. Nebraska M. J. 34:17, 1949.

15. Butler, E. B., and McKnight, E.: Vitamin E in treatment
of primary dysmenorrhoea. Lancet 1:844, 1955.

16. Hudgins, A. P.: Vitamins P, C and niacin for dysmenorrhea
therapy. West J. Surg. 62:610, 1954.

17. Macpherson, C.: Pelvic allergy. Canad. M. A. J. 60:54,

1949.

18. Maietta, A. L.: Effect of thephorin upon primary dysmen-

orrhea. Ann. Allergy 10:324, 1952.

19. Chamblin, W. D., and Corbit, J. D., Jr.: Chlorproma/.ine

and chlorpromazine combinations in treatment of dysmenor-
rhea. Am. J. Obst. & Gynec. 74:419, 1957.

20. Hunter, R. G., Henry, G. W., and Heinicke, R. M.: Ac-
tion of papain and bromelain on the uterus. Am. J. Obst. &
Gynec. 73:867, 1957.

21. Black, W. T., Jr.: Presacral neurectomy; report of 70 cases.
South. M. J. 48:120, 1955.

22. Doyle, J. B.: Paracervical uterine denervation by transection
of cervical plexus for relief of dysmenorrhea. Am. J. Obst. &
Gynec. 70:1, 1955.

Book Reviews on Pain

NERVES EXPLAINED: A STRAIGHTFORWARD

GUIDE TO NERVOUS ILLNESSES, by Richard
Asher, M.D., F.R.C.P., physician. The Central Mid-
dlesex Hospital, 1958. Springfield, Illinois: Charles

C Thomas, 157 pages. $2.75.

The author of this small book is a British general prac-
titioner who says he does not believe there should be
“any clear division between physician and psychiatrist.”
Quoting Terence, he presents this motto: “As a man I
am concerned with everything to do with mankind.”
This book was written to afford the author an oppor-
tunity to present his convictions about the nervous sys-
tem. The plan of the book is to consider the various nerv-
ous illnesses according to the terms commonly used for
them, and the chapters are arranged systematically on
such a basis. He has explained what each condition is
and what he thinks can be done about each one, and he
has used a form of writing which the ordinary reader
can readily understand.

The book is easily read. It is indexed. It presents a
very rational point of view in conveying by means of
words the mental picture the author has before him

when he is dealing with a form of nervousness or nervous
illness.

John S. Lundy, M.D.

•

SPINAL ANESTHESIA, by John B. Dillon, M.D., pro-
fessor of surgery and chief of the Division of Anes-
thesia, Department of Surgery, University of Califor-
nia Medical Center, Los Angeles, 1957. Springfield,
Illinois: Charles C Thomas, 61 pages. $3.00.

In the preface the author says, “This monograph is writ-
ten in the hope that it will assist the physician who per-
forms spinal anesthesia, but who has had neither the
time nor the opportunity to explore some of its facets.
It is hoped that it wili be a stimulus to residents in
Anesthesiology by causing them to look further into
many phases of spinal anesthesia about which there is
still much to learn.

“The point of view taken on techniques and dosages
is conservative but known to work within the limits
prescribed.”

This he should accomplish.

John S. Lundy, M.D.
JULY 1958 327

Section on PAIN

Current Literature on Pain

THE EFFECT OF NISENTIL (ALPHAPRODINE)
HYDROCHLORIDE AND LORFAN T. M. (LE-
VALLORPHAN) TARTRATE ON RESPIRATION,
by |ack Auerbach and C. S. Coakley: Anesth. &
Analg. 45:460-467, 1956.

“It appeared logical that the combined use of alpha-
prodine with levallorphan might be advantageous in the
management of labor in that it would permit the admin-
istration of more liberal doses of the narcotic, with cor-
respondingly more complete analgesia, without any un-
toward effect on respiratory function of mother or infant.
Since alphaprodine is usually given subcutaneously to
patients in labor, it seemed advisable, before embarking
on a study of this drug in obstetrics, to investigate its
effects by this route in combination with levallorphan
at varying dosage ratios and in other conditions ....

“A study was made of 69 cases in which the patients’
ages ranged from 15 to 67 years .... The 69 patients
were divided into two groups: 27 received alphaprodine
alone and 42 were given alphaprodine in combination
with levallorphan ....

“Respiratory rates and minute volumes were deter-
mined for all 69 subjects initially and 15, 30, 45 and 60
minutes after administration of the drug. Alphaprodine
alone decreased the respiratory rate insignificantly and
reduced the respiratory minute volume to 78.4 per cent
of the control value ( fifteen minutes after the administra-
tion of the drug). The addition of levallorphan to alpha-
prodine increased the respiratory rates to control values
or above at almost all readings.

“The use of one part or more of levallorphan with 20
parts of alphaprodine gave maximal reversal of depres-
sion of respiratory minute volume. The combination of
alphaprodine and levallorphan in the ratio of 20:1 pro-
duced a minimum of side effects. The analgesic property
of alphaprodine was not diminished by the addition of
levallorphan in any of the ratios used. It is concluded
that levallorphan is effective in preventing alphaprodine-
induced respiratory depression when both drugs are in-
jected subcutaneously.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 11. Copyright by John S. Lundy.

HERNIORRAPHY IN THE POOR-RISK PATIENT,
bv P. H. Beves and C. H. J. Rey: Anesthesia 11:311-
318, 1956.

“This is a report on 22 cases of repair of herniae in pa-
tients who were considered poor operative risks, to show
that satisfactory operating conditions can be provided by
the use of the ‘lvtic cocktail’ — chlorpromazine, prometh-
azine and pethidine in various proportions — and local
analgesia .... The eldest patient was 86 and the
youngest 56 ... .

“Fifty milligrams of each drug are drawn up into a
20 ml. syringe and diluted to 20 ml. with normal saline.
Extra pethidine (and rarely chlorpromazine also) is given
separately if it seems desirable as the operation proceeds.
Five patients received 50 mg. of each drug. Six patients
received 50 mg. of chlorpromazine, 50 mg. of prometha-
zine, and 100 mg. of pethidine. The other 11 received
total doses of chlorpromazine varying from 25 to 75 mg.;
of promethazine varying from 20 to 50 mg.; and of pethi-
dine varying from 30 to 150 mg A Ryle’s tube is

passed and aspirated pre-operatively only in those pa-
tients who give a history of copious or foul vomiting, or
where there is any doubt about the reliability of the pa-
tient’s story. Strong cortical depressants such as mor-
phine are absolutely contraindicated ....

“The ‘cocktail’ is administered intravenously after
dilution; it is given slowly, four minutes being taken for
the injection. The patient is immediately transferred to
the operating table and reassured; the legs and thighs are
lightly strapped down and the hands held on the pa-
tient’s chest by a nurse. After painting the skin with
tincture of iodine and towelling up, the infiltration is
commenced ( about five minutes after the intravenous
injection has been completed ) . A slight movement of the
patient is often noticed as the needle is inserted. Pro-
caine hydrochloride (0.5 per cent) without adrenaline
is employed and is injected with a 5 in. ( 12.7 cm. )
needle through one puncture wound only. Infiltration is
limited to a subcutaneous area just beyond the limits of
the proposed skin incision, together with an injection
into the muscular planes 1 in. (2.5 cm.) medial to
the anterior superior iliac spine with the intention of
blocking the ilioinguinal nerve. The average volume used
is 70 ml. (2 oz. ). We have found further infiltration of
the muscular planes and peritoneum unnecessary. Pre-
sumably such deep structures as are eneountered arc ren-
dered sufficiently insensitive by the ‘cocktail.’ Chlor-
promazine is adrenolytic and is likely to inactivate am
adrenaline added to the local analgesics. We have used
procaine without adrenaline and had no trouble from
vasodilation ....

“The majority of patients sleep for several hours, re-
quire no postoperative sedation, and when visited the
next day often do not realize that they have had their
operation. A few, especially those who have had a small-
er dose of promethazine, are awake earlier and require
some sedation. Pethidine in doses of 10 to 30 mg. intra-
muscularly is given when required. The nursing staff
is warned that NO morphia, no extra blanket and no
hot water bottles be given .... The average length
of stay in the hospital was fifteen days. There were 2
deaths, neither of which was directly attributable to the
operation.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, pages 22-23. Copyright by John S. Lundy.

328

THE JOURNAL-LANCET

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21 A

Stress and Strain in Bones, by F.
Gaynor Evans, Ph.D., 1957.
Springfield, Illinois: Charles C

Thomas, 227 pages. $6.50.

This book presents a survey on stress
in long bones, the skull, and the
spinal column under physiologic and
pathologic conditions. Some of the
more recent experimental work in
this field is included and combined
with the author’s own studies on
several special subjects.

The book begins with an explana-
tion of the terms “stress and strain”
and continues with a description of
the various methods used to meas-
ure and study these conditions. The
first part of the book applies more
to the theoretic side of the subject,
whereas the second part engages in
the interesting data for clinical use,
such as the effect of stress in bone
healing and growth, the influence of
stress in osteogenesis, the factors in-
fluencing breaking strength, and so
on.

The author is aware of the fact
that many of the studies were not
carried out under physiologic condi-
tions, which naturally limits the
practical use of the gained knowl-
edge.

John H. Moe, M.D.

•

llmnan Blood Coagulation and Its
Disorders, by Rosemary Biggs,
M.D., and R. G. MacFarlane,
M.D., ed. 2, 1957. Springfield,
Illinois: Charles C Thomas, 476
pages. $8.50.

In the rapidly advancing field of
blood coagulation, frequent reviews
are desirable. A textbook covering
the entire subject of coagulation will
be obsolete in some respects even
at the date of publication, but such
a book nevertheless can satisfy a
great need bv presenting in organ-
ized, lucid form a large and complex
subject.

This second edition of a work first
published in 1953 has been enlarged
to present in current perspective the
concepts and technics as well as the
development of knowledge of co-
agulation. Part I deals with experi-
mental observations and interpreta-
tions of various workers and the
theories of the coagulation mechan-
ism which have evolved from their
researches. The known coagulation
factors and their place in the co-
ngelation scheme are discussed. Dif-
ferentiation between the intrinsic
system (blood thromboplastin) and
the extrinsic system (tissue extracts)
is emphasized; the section on plas-
ma thromboplastin is particularly

good. The phenomena of natural
inhibitors, clot retraction, and fi-
brinolysis are discussed. Descrip-
tions and evaluations of specific
tests of clotting functions are pre-
sented.

Part II considers the disorders of
blood coagulation from a clinical
point of view and includes descrip-
tions of clinical manifestations, clot-
ting abnormalities, laboratory find-
ings, and treatments. Thrombosis
and anticoagulant therapy are dis-
cussed.

The appendices include a glossary
of terms, an outline of the system-
atic approach to investigation of
coagulation defects, and detailed
methods for the preparation of re-
agents and coagulation factors and
for tests of clotting function

This is a comprehensive and stim-
ulating book. It is written with au-
thority and with as much clarity
and simplicity as the present state
of knowledge and confusion in this
field of endeavor appears to allow.

Lorraine Gonyea

•

An International Nomenclature of
Yaws Lesions, by C. [. Hackett,
M.D., F.R.C.P., medical officer,
Venereal Diseases and Trepone-
matoses Section, WHO, 1957. No.
36 of the World Health Organiza-
tion Monograph Series. World
Health Organization, 103 pages.
$4.00.

Dr. Hackett, whose long acquaint-
ance with yaws is well known, has
supplied in this small volume a com-
plete guide to the nomenclature of
earlv and late yaws lesions based
upon his own experience and
checked with other experts in this
nonvenereal form of treponematosis.
He has thereby removed the possi-
bility of confusion in the description
and the discussion of gross lesions
in the bones, skin, and mucous
membranes.

The most remarkable feature of
this monograph, however, is the sec-
tion of illustrations, numbering 76
and constituting an atlas of the ex-
ternal and roentgenographic mani-

festations of yaws. The photographs
are technically excellent, and each
has been carefully selected for its
purpose.

Dr. Haekett’s classification and atlas
promises to assist the clinician not
only in countries in which yaws is
prevalent but also in those subtrop-
ical and temperate regions where
treponematosis is present in the form
of endemic syphilis and where ex-
actly the same conditions of bone,
skin, and mucous membrane are to
be found. Presumably, Dr. Hackett
still holds the view that Treponema
pertenue is a valid species and yaws
a different disease than syphilis, but
this monograph provides good sup-
porting evidence of the essential
unity of world-wide treponematosis.

This monograph would be a val-
uable addition to the library of clini-
cians and pathologists dealing with
some phase of treponematosis. It
should be available in every medical
school library to show the present
day medical student what kinds of
lesions Treponema pallidum pro-
duces when it is propagated endem-
ieally and nonvenereally among the
primitive peoples of some regions of
the world.

E. H. Hudson, M.D.

•

Multiple Neurofibromatosis, by
Frank W. Crowe, M.D., Wil-
liam J. Schull, Ph.D., and
James V. Neel, M.D., Ph.D.,
1956. Springfield, Illinois: Charles
C Thomas, 181 pages. $5.00.
This monograph is one in a series of
American Lectures in Dermatology.
The authors are dermatologists and
geneticists from the School of Medi-
cine and the Heredity Clinic of the
Institute of Human Biology at the
University of Michigan. Emphasis in
this book is, therefore, primarily on
skin manifestations and the heredi-
tary aspects of Recklinghausen’s dis-
ease, though brief discussions of the
osseous and central nervous system
involvement as well as a summary
of the pathology is also included.
Nearly one-half of the pages are de-
voted to a systematic description of
223 affected persons who, with their
families, formed the basis for this
clinical, pathologic, and genetic
study. Separate chapters are also
devoted to the frequency of neuro-
fibromatosis and the genetics of both
the familial and sporadic cases.

This book is of interest particu-
larly to dermatologists and geneti-
cists, but it also contains material of
value for neurologists and roentgen-
ologists.

Erland Nelson. M.D.

22A

*T$fie 1

Journal

I Ji III K' I SERVING THE MEDICAL PROFESSION OF MINNESOTA,

1 LA, | l/l»Ly|» NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

The Outlook of Vascular Surgery
Upon the Aged

CLAUDE R. HITCHCOCK, M.D., and
THOMAS O. MURPHY, M.D.

Minneapolis, Minnesota

The aging process of blood vessels has be-
come a leading cause of death, for currently
at least 200,000 persons die in the United States
each year of vascular system diseases. This group
represents annually about one-seventh of deaths
from all causes in this country. Undoubtedly,
recent advances in the control of infectious dis-
eases and continued growth and proficiency in
all branches of the medical profession through
research have created an atmosphere wherein
people may expect a longevity well into the sev-
enth decade. Pending a form of medical therapy
for arteriosclerosis or a method of prophylaxis
against this degenerative disease, we can ex-
pect a continuous increase in the group of pa-
tients seriously afflicted with arteriosclerosis or
its sequelae.

In the present series of patients with “sur-
gical" vascular disease treated at the University
of Minnesota Hospitals and the Minneapolis
General Hospital up to September 1, 1957, 96
per cent of 260 patients operated upon were 55

claude r. hitchcock is associate professor of sur-
gery at the University of Minnesota and chief of
surgery at Minneapolis General Hospital, thomas
o. murphy was formerly instructor in surgery at the
University of Minnesota; currently he is a member
i of the Department of Surgery at the University of
1 Washington.

Paper presented at the annual meeting of the
| Society of Gerontology, Cleveland, October 1957.

years of age or older at the time of surgery.
There were 150 patients with occlusive arterial
disease, and 91 per cent were age 60 or over
as noted in table 1. One hundred and seven,
or 71 per cent, of patients in this group were
between the ages of 60 and 75 years, while 29,
or 18 per cent, were between 75 and 90.

A total of 110 patients have been treated for
arterial aneurysms and, again, 90 per cent were
60 years of age or older at the time of surgery.
Seventy-four, or 67 per cent, were between the
ages of 60 and 75 years; 25, or 22.7 per cent,
were over 75 at the time of surgery (table 2).

The ability of older patients to survive and re-
cover from major arterial surgery is noteworthy.
The 2 prime deterrents to corrective surgery
have been serious cardiac disease or advanced
pulmonary disease. In our experience, the major
risk rests with anesthesia, and final decisions re-
garding operation are usually made by the anes-
thesiologist. Frequently, our anesthesiologists are
confident of a successful operation in a patient
considered by the internists to be too poor a
risk for surgery.

The high degree of success in the present
series of cases — 87 per cent success with elective
aneurysmectomy and 76 per cent success in by-
passing for occlusive disease — adequately sub-
stantiates the advisability and value of the direct
surgical approach in these patients. Important
to success in this type of surgery is the assur-
ance that, following successful technical recon-

TABLE 1

ACE DISTRIBUTION

IN OCCLUSIVE ARTERIAL

DISEASE

Years of age

Under 50

l

50 to 55

2

55 to 60

10

60 to 65

27 i

1

65 to 70

44

v 71%

70 to 75

36 '

1

75 to 80

10 j

1

80 to 85

15

18%

85 to 90

4 <

1

90 to 95

1

150

TABLE 2

ACE DISTRIBUTION

OF

PATIENTS WITH ARTERIAL

ANEURYSMS

Years of age

Under 50

l

50 to 55

6

55 to 60

4

60 to 65

18

I

65 to 70

20

67%

70 to 75

36

)

75 to 80

20

} 22.7%

80 to 85

5

110

1

stitution of more normal blood flow to provide
more normal perfusion of tissues, there are no
major physiologic alterations in the patient’s
body which require over-all or prolonged bodily
adjustments. Anticoagulation with heparin dur-
ing surgery is well tolerated, and the major tech-
nical problem to be managed is the maintenance
of the blood volume of the patient at or close
to the optimum for the patient’s cardiac status.

We believe that, with careful attention to tech-
nical details at surgery and judicious use of anes-
thesia provided by experts, most patients can be
successfully operated upon for major arterial
diseases irrespective of age.

SURGICAL INDICATIONS FOR VASCULAR
RECONSTITUTION

At the present time, we feel that the presence
of an arterial aneurysm is sufficient justification
for surgical repair of the lesion. Recently, the
natural history of aneurysms was reported by
Estes,1 who showed that 33 per cent of 102 pa-
tients with untreated abdominal aneurysms died
within the first year after the lesion was recog-
nized. Only 18 per cent of his series of patients
survived five years without surgery. Rupture of
an aortic aneurysm is universally fatal unless
immediate surgical repair is effected. To our
knowledge, no patient with a truly “ruptured”
aneurysm has survived six months without sur-
gical therapy. The only primary contraindication
to the surgical correction of an aneurysm is car-
diovascular-pulmonary disease of such a serious

r i

v Si

ir •

. i

!>.* aHH

Fig. I. Aortograms demonstrating an enlarged mesenteric artery providing collateral flow around an obstruction of
the distal aorta in an 82-year-old man. This patient could walk 6 blocks without difficulty; arterial by-pass not
indicated at this time.

330

THE JOURNAL-LANCET

nature that the patient is not a candidate for
general anesthesia over a prolonged period of
time.

Patients suffering from occlusive arterial dis-
ease present a more difficult problem in evaluat-
ing the necessity for a surgical procedure. Fol-
lowing are 3 important considerations in our
evaluation of these patients:

1. Claudication as a symptom of occlusive dis-
ease must be present and sufficiently severe to
cause limited activity. Figure 1 shows aorto-
grams of an 82-year-old man who had extensive
collateral circulation around an atherosclerotic
occlusion of his aorta below the renal arteries.
The rich network of collateral vessels enabled
this elderly man to walk 6 blocks without diffi-
culty. Such a patient should be managed con-
servatively until evidence of impending gan-
grene indicates the necessity of a surgical by-
pass of the occluded portion of the vessel.

2. Peripheral pulsations below the suspected
site of arterial occlusion must be absent. In a
series of over 300 arterial angiograms2 performed
at the University Hospitals and the Minneapolis
General Hospital, the distal pulses were absent
in all cases of true arterial occlusion. The pres-
ence of distal pulses in conjunction with claudi-
cation indicates the likelihood of an arterial
stenosis but not true obstruction.

3. Angiographic demonstration of the site of
obstruction is highly beneficial. Such roentgeno-
grams may be performed safely and without
anesthesia when the lesion is below the inguinal
ligament or in the distal portion of the upper
extremity. These angiograms give confirmatory
evidence as to the type, extent, and nature of
the arterial occlusion and permit an excellent
evaluation of the patency of arteries distal to the
point of occlusion. It is paramount that an ade-
quate distal arterial “run-off” be present for the
success of an arterial graft or shunt.

In patients presenting the symptomatology
noted in the Leriche syndrome — thrombosis of
the bifurcation of the aorta — we have preferred
to determine the feasibility of performing a by-
pass shunt from the aorta to the femoral arteries
by directly visualizing the bifurcations of the
common femoral arteries through a small incision
in each groin. If the superficial femoral arteries
and the profunda femoris arteries are patent, the
patient is a candidate for a shunt procedure.
Almost universally, a satisfactory proximal site
can be found for the origin of the by-pass graft
if the distal arteries are adequate to carry the
arterial “run-off.” After an initial experience of
performing angiograms on virtually all patients
suspected of arterial disease,2 we now tend to

TABLE 3

ARTERIAL ANEURYSMS

Artery

Number

Successes

Failures

Expired

Carotid

1

1

Axillary

1

1

Aortic arch

2

0

0

2

Thoracic arch

it

5

0

6

Abdominal aorta

45

37

2

6

Bifurcation aorta

42

31

2

9

F emoral

3

1

1

1

Popliteal

5

4

1

0

110

80

6

24

use this diagnostic tool less frequently and com-
monly base surgical correction on the obvious
clinical signs and symptoms of the disease.

ARTERIAL ANEURYSMS

One hundred and ten aneurysms of the aorta
have been diagnosed and excised in 103 patients
from 1954 to 1957 at the University of Minne-
sota Clinics and the Minneapolis General Hos-
pital (table 3). These patients ranged in age
from 16 to 84 years. Eighty-seven aneurysms
were in the abdominal aorta, 13 were in the
thoracic aorta, and 10 were in peripheral ves-
sels. Ninety-two operations were elective in
character, while the aneurysms had ruptured in
18 patients necessitating immediate emergency
surgical repair. In the 18 patients operated upon
for ruptured aneurysms, 14 deaths occurred anti
only 4 patients were successfully repaired (suc-
cess rate of 29 per cent). On the other hand,
in the group of 92 patients operated upon elec-
tively for aneurysms, there were only 10 deaths,
and 8 of these patients had aneurysms of the
thoracic aorta (success rate of 87 per cent). Of
the 92 patients, 6 were classed as failures due
to either a secondary thrombosis or a late rup-
ture of the prosthesis used for the arterial re-
constitution. Five of these patients were re-
operated upon, and regrafting was accomplished
successfully in 4. Thus, the success rate for the
whole group of elective aneurysm operations is
87 per cent as compared with a 29 per cent suc-
cess rate in those cases in which the aneurysms
had ruptured (table 4).

OCCLUSIVE ARTERIAL DISEASE

One hundred and fifty operations have been per-
formed for segmental occlusive arterial disease.
An attempt was made in each case to either by-
pass the occluded segment or to replace the
blood vessel in continuity. Six patients had a
classical Leriche syndrome with thrombosis of

AUGUST 1958

331

TABLE 4

ARTERIAL ANEURYSMS

Number lesions 110

Operations 114

S accesses

Patients 103
Failures or
expired

All aneurysms resected

76%

24%

Elective operations

87%

13%

Ruptured aneurysms

29%

69%

Thoracic aneurysms

38%

62%

Abdominal aneurysms

82%

18%

Peripheral aneurysms

90%

10%

the distal aorta, and these eases necessitated
replacement of the bifurcation of the aorta with
a graft. Four of these operations have been
successful, while 1 graft thrombosed at three
months but amputation was not necessary. One
patient expired after an immediate thrombosis
of the graft. Figure 2 demonstrates one method
of alleviating this syndrome by means of a by-
pass technic of the aortic bifurcation. In the
other 3 patients in whom the operations were
successful, a replacement technic was utilized
effecting direct arterial continuity.

Forty-eight patients were operated upon for
thrombosis of the common iliac or external iliac
arteries, and a by-pass tvpe of repair was per-
formed. In 44 of these patients, the by-pass has
been successful, while, in 13 instances, the by-
pass graft has subsequently thrombosed. How-
ever, in none of the patients with subsequent
thrombosis of the by-pass graft has an amputa-
tion been necessary. Three of the patients in the
failure group had obvious gangrene of their
distal extremity prior to the surgical attempt to

Fig. 2. Arterial homograft used to by-pass the aortic bi-
furcation which has become thrombosed (Leriche syn-
drome). Continuity has been re-established from the
proximal open aorta to both common iliac arteries distal
to the thrombosis.

revascularize the limb. One patient expired fol-
lowing a cardiac arrest during the induction of
anesthesia preparatory for an operation of this
nature. It is noteworthy that in spite of the ad-
vanced age of these patients and the presence of
serious cardiac and pulmonary disease, modern
methods of anesthesia permit the performance
of this type of vascular surgery with significant
safety. Furthermore, operations upon occluded
peripheral arteries can frequently be performed
under local anesthesia with complete comfort
to the patient.

THROMBOSIS OF SUPERFICIAL FEMORAL
ARTERY

Seventy-four patients had thrombosis of a super-
ficial femoral artery, usually in the region of
Hunter’s canal. The operation employed in our
clinics for alleviation of the claudication of the
calf and the ischemia of the foot and lower leg
has been a subcutaneous by-pass from the com-
mon femoral artery to the popliteal artery princi-
pally using crimped nylon shunts. Of the 74
operations attempting to by-pass obstructions
of this kind, 58 have been successful and 15
were failures. One patient died shortly after sur-
gery from thrombosis of an occult aortic aneu-
rysm which had not been recognized during the
femoral-popliteal by-pass graft procedure, which
was done with a concomitant lumbar sympathec-
tomy. A lumbar sympathectomy was performed
in a significant number of these patients either
prior to or concomitant with the arterial recon-
stitution if the patient was in good general health
and under 65 years of age. The success rate for
femoral-popliteal by-pass shunts has been 79 per
cent in our clinics. Shunts have proved highly
successful when employed to bridge thromboses
in the common or external iliacs and in the dis-
tal femoral arteries. Furthermore, by-pass of an
occluded segment of the popliteal artery in 2
patients has been successful with the use of
autogenous vein grafts in these cases ( tables 5
and 6 and figure 3).

DISCUSSION

The net physiologic benefit from a successful
arterial reconstitution has been well demonstrat-
ed in the studies of Creech.3 A more efficient
transmission of blood flow and pulse pressure
into the distal vascular bed following such
surgery has been made possible by means of
plethysmographic measurements of peripheral
blood flow, ergometric evaluations of the pa-
tient on a treadmill, and by the patient's sub-
jective evaluation as he has returned to activitv.
The tolerance of the elderly patient toward ex-

332

THE JOURNAL-LANCET

Fig. 3. Aortograms demonstrating a nylon by-pass teclinic. Blood is shunted from the left common iliac artery to
the left superficial femoral artery, by-passing an obstructed common iliac and external iliac artery, (a). Obstruction
at the bifurcation of the common iliac artery on the left side. (b). Prosthesis graft in place with adequate distal flow.

TABLE 5

OCCLUSIVE ARTERIAL DISEASE

Artery

Number Successes Failures Expired

Carotid

7

3 3

1

Subclavian

3

3

Aortic bifurcation

6

4 1

1

Aorta-femoral

21

16 5

0

Iliac

12

10 2

0

Ilio-femoral

25

18 6

1

Femoral-popliteal

74

58 15

1

Popliteal

2

2 0

0

150

114 32

4

Nine months shortest follow-up.

TABLE

6

OCCLUSIVE ARTERIAL DISEASE

Failures or

Artery

S uccesses

expired

Carotid

43%

57%

Axillary

100%

—

Aortic bifurcation

67%

33%

Aorta-femoral

82%

18%

Femoral-popliteal

79%

21%

Popliteal

100%

— 1

Over-all

76%

24%

tensive vascular surgerv lias been emphasized,
and with advanced methods of anesthesia and
prevention of hypotension during and after sur-
gery, the results appear to be excellent. Arterial
wounds and skin incisions in such patients have

healed rapidly, and usually hospitalization has
not been required longer than fourteen to eight-
een days.

The ever present problem of accepting the
surgical risk of removing a serious aortic aneu-
rysm in the aged patient is real. However, ac-
ceptance of conservative therapy imposes a poor
prognosis upon the patient in terms of the high
incidence of rupture of the lesion and the poor
surgical result in these cases. Mortality has been
69 per cent in our hands. On the other hand,
in our series, there have been only 2 deaths
associated with elective operation for abdominal
aortic aneurysm.

The problem of removing aneurysms of the
thoracic aorta are great, and we have had a
62 per cent mortality for cases of this type.
A pump oxygenator was utilized in 3 patients
to by-pass the arch of the aorta during its re-
moval — taking blood from a femoral vein and
returning it to the femoral artery — and, in 2
more cases, a shunt assisted by a pump was
used from the left auricle to the femoral artery
in order to furnish oxygenated blood to the ab-
dominal organs during the period of cross-clamp-
ing of the thoracic aorta. In those cases in
which the pump oxygenator was used to with-
draw blood from the femoral vein and return
it to the femoral artery, Arfonad was employed
to prevent hypertension in the upper extremities
and the head. Technical proficiency must be de-
veloped in each institution performing such sur-
gery in order that aneurysms of this type can
be managed with increasing safety. Undoubt-

AUGUST 1958

333

edly, many surgical clinics will be successfully
removing aneurysms of the thoracic aorta and
reconstituting a normal How in the very near
future.

In those patients with occlusive arterial dis-
ease, the decision to attempt a revascularization
of the involved portion of the body ultimately
depends upon the severity of the patient’s symp-
toms or the presence of impending gangrene.
Obviously, the patient without symptoms will
not present for surgical correction of a lesion
even if an arterial occlusion is known to exist.
Indeed, no evidence at this time indicates that
prophylactic revascularization of an asympto-
matic extremity with occlusive arterial disease
is of significant benefit.

The majority of our patients operated upon
for segmental arterial occlusions have received
a by-pass type of arterial reconstitution rather
than an in-line graft establishing direct continu-
ity of the blood flow. Technically, the by-pass
graft is easier to accomplish, since the arteries
involved in the extremities are usually relatively
normal, and end-to-side anastomoses are done
with ease. Furthermore, the employment of the
by-pass shunt technic does not damage small
collateral arteries that are so important to the
problem of distal “run-off.” In addition, in the
event of a subsequent thrombosis of the by-pass
shunt graft, the original vascular supply to the
extremity is not significantly changed, and the
limb, therefore, is not jeopardized. Recent re-
ports from the clinic of Robert Linton4 have
demonstrated a higher incidence of patency of
the by-pass shunt grafts during a follow-up of
early cases as contrasted with resections and in-
continuity graftings.

The presence of an arterial stenosis does not
constitute an indication for vascular reconstitu-
tion in our clinics. If a stenotic area is by-
passed, the narrowed segment will immediately
thrombose after the insertion of the by-pass
shunt. If the graft then subsequently fails, as it
does in 24 per cent of cases, the limb has been
jeopardized due to a significantly diminished
blood flow. In contrast, the failure of a by-pass
shunt graft around a completely occluded seg-
ment of an artery does not significantly alter the
blood supply to the distal portion of the limb
as mentioned earlier.

Cerebral claudication on the basis of segmen-
tal obstruction of an internal carotid artery has
been demonstrated in 7 patients in our clinic.
These people presented with symptoms of dizzi-
ness, mental confusion, and memory disturb-
ances and were found to have a unilateral oc-
clusion of one carotid artery. Revascularization

utilizing venous autogenous grafts was attempt-
ed in these patients. Three of them have been
treated successfully, and 3 of the grafts ultimate-
ly thrombosed. One patient lapsed into coma and
expired five days after such an operation, even
though a patent graft could be palpated in the
cervical area. Recently, it has been reported
from other clinics that considerable success with
lesions of this kind has been noted after end-
arterectomy of these segments. Although our
attempts at cerebral revascularization are few
and the follow-up is short, the initial results
indicate that benefits are to be derived from fur-
ther attempts to improve these patients with sur-
gery.

SUMMARY AND CONCLUSIONS

1’he surgical experience with 110 arterial aneu-
rysms and 150 cases of segmental occlusive ar-
terial disease has been presented from the Uni-
versity of Minnesota clinics and the Minneapolis
General Hospital. In 76 per cent of patients
operated upon for correction of a major arterial
aneurysm, the procedure was successful. The
age of our patients ranged from 16 to 84 years.
The significant difference in the success rate of
resection of aortic aneurysms in the elective
stage as against the ruptured stage — 87 per cent
compared with 29 per cent — has been empha-
sized. Most of our success has resulted from the
repair of abdominal and peripheral aneurysms.

The surgical correction of occlusive arterial
disease utilizing principally by-pass shunt grafts
has been presented. The success rate in our
clinics for by-pass shunts is as follows: aorta-
femoral, 82 per cent; femoral-popliteal, 79 per
cent; popliteal, 100 per cent.

The generalized nature of the process of ar-
teriosclerosis in the patient’s body must be ap-
preciated, and these surgical procedures have
been presented as a palliative approach in the
over-all problem of the treatment of arterio-
sclerosis. Undoubtedly, future studies of the me-
tabolism of lipids and the dietary factors of vari-
ous ethnic groups will indicate possible methods
of prophylaxis against the development of se-
vere atherosclerosis. However, as physicians, we
must be courageous in our attempts to prolong
the life of our patients in a manner permitting
maximum usefulness of all of their faculties.
We believe the current surgical approach to
serious vascular disease, as outlined in this re-
port, has a significant part to play in the attain-
ment of this goal at the present time.

Arfonad, tri-methane tri-methathane camphor sulfonate
used as a Vi per cent intravenous drip, was provided by
Hoffmann-LaRoche, Inc.

334

THE JOURNAL-LANCET

REFERENCES

1. Estes, J. E.: Abdominal aortic aneurysm: study of 102

cases. Circulation 2:258, 1950.

2. Margulis, A. R., Nice, C. M., |r., and Murphy, T. O.:
Arteriographic manifestations of peripheral occlusive vascular
disease. Am. J. Roentgenol. 78:27.3, 1957.

3. Creech, O., Jr., DeBakey, M. E., Culotta, R.: Digital

blood flow following reconstructive arterial surgery. Arch.
Surg. 74:5, 1957.

4. Linton, R. R., and NIendendez, C. V.: Arterial homografts:
comparison of results with end-to-end and end-to-side vascu-
lar anastomoses. Ann. Surg. 142:568, 1955.

ADDITIONAL BIBLIOGRAPHY

1. Watts, S. H.: Suture of blood vessels: implantation and

transplantation of vessels and organs. Bull. lohns Hopkins
Hosp. 18:153, 1907.

2. Gunthrie, C. C.: Transplantation of formaldehyde fixed

blood vessels. Science 27:473, 1908.

3. Carrel, A.: Preservation of tissues and its application in

surgery. J.A.M.A. 59:523, 1912.

4. Hoepfner, E.: Ueber Gefaessnaht, Gefaesstransplantationen

und Replantation von Amputierten Extremitaeten. Arch, clin
chir. 70:417, 1903.

5. Williamson, C. S., and Mann, F. C.: Functional survival of
autogenous and homogenous transplants of hlood vessels
Arch. Surg. 54:529, 1947.

6. Gross, R. E.. Hurwitt, E. S., Bill, A. II., Jr., and Peirce,

E. C.: Preliminary observations on use of human arterial

grafts in treatment of certain cardiovascular defects. New
England J. Med. 239:578, 1948.

7. Kunlin, J,: Le traitement de Pischemie arterique par la

graffe veineuse longue. Rev. de chir. Nos. 7-8, July-August,
1951.

8. Harris, E. J., and others: Pliable plastic aortic grafts; ex-

perimental comparison of a number of materials. A.M.A.
Arch. Surg., 71:449, 1955.

9. Shumway, N. E., Gliedman, M. L., and Lewis, F. J.: Ex-
perimental study of the use of polyvinyl sponge for aortic
grafts. Surg., Gynec. & Obst. 100:703, 19.55.

10. Hufnacel, C. A.: Occlusive arterial disease. Minnesota

Med. 38.912, 1955.

Undiscovered stones in the common ducts are the most frequent cause of
symptoms of. biliary disease which persist after cholecystectomy. A normal
operative cholangiogram is no assurance that the common duct is free of
stones, and, if sufficient clinical evidence exists, choledochotomy should be
performed.

Of 100 consecutive patients in whom choledochotomy was performed, with
removal of common duct stones, 94 were observed for four to six years. Results
seem to uphold the soundness of broad indications for this procedure. In the
entire series, operative cholangiography was used secondarily to mechanical
exploration in detection of stones. Symptoms recurred in only 3 patients —
in 2, within one year and, in 1, after four years. Reoperation revealed that
2 patients had previously overlooked or recurrent stone formation and 1 had
extensive sclerosing cholangitis.

In another 20 patients who had had common duct exploration prior to
referral and who required reoperation for persisting symptoms, preoperative
roentgen films showed retained stones in 9. At surgery, multiple stones were
found in 11.

Svmptoms again recurred in 2 of these patients. At operation, infection
and stasis were found in the biliary duct system of both patients, with appar-
ently recurrent stone formation. In such patients, sphincterotomy should be
performed in order to allow freer drainage of the biliary tract.

Bentley P. Colcock, M.D., and Harold V. Liddle, M.D., Lahey Clinic, Boston. New England
J. Med. 258:264, 1958.

AUGUST 1958

335

Lesions of the Oral Mucosa
in Some Systemic Diseases

HAROLD O. PERRY, M.D.
Rochester, Minnesota

Inspection and evaluation of the oral cavity
should be an integral part of any general
physical examination. The changes found in oral
tissues may be extremely varied. The abnormali-
ties present may be indicative of local disease,
or the changes, although minor, may reflect a
more generalized pathologic process. Thus, fa-
miliarity with the various tissue reactions of the
oral cavity as they are a part of systemic disease
may enable the physician to evaluate the entire
patient in a more direct manner and may indi-
cate the direction in which the laboratory evalu-
ation should proceed.

The importance of knowledge of the oral
cavity was recently the subject of an editorial1
with which 1 am in agreement. The author stated
as follows: “Sir William Osier has called the oral
cavity a mirror of the rest of the body. Yet while
the changes in eyegrounds that are associated
with systemic diseases are well recognized, the
changes in and around the mouth do not seem
to have equal appreciation by the physician.

“Oral tissues are unusually sensitive indicators
of the general health status of an individual.
This easily accessible, painless diagnostic site
particularly reflects initial signs of nutritional
deficiencies, endocrine imbalances, gastrointesti-
nal disturbances, communicable diseases, blood
dvscrasias including the anemias, and excessive
exposure to radioactivity.”

For purposes of this discussion, I should like
to present pictures of diseases of the oral cavitv
as if one were looking at them with “gun-barrel
vision.” Thus, we will exclude from unconscious
consideration the associated cutaneous findings
and the general status of the patient and rely
onlv on that information obtained by visualizing
the oral cavity alone through the lens of the
camera. We then can better assess the value of

harold o. perry is a member of the Section of
Dermatology at the Mayo Clinic.

Paper presented at a staff meeting of the Veterans
Administration Hospital at Minot, North Dakota,
May 15, 1958.

the findings in the oral mucous membrane if
we see them alone and can determine to what
degree they may be utilized as a diagnostic tool.

The spectrum of diseases presented for evalu-
ation may be extremely varied, including de-
velopmental anomalies; infections caused by bac-
terial, spirochetal, viral, or mycotic organisms;
mucosal changes produced by the contact and
ingestion of certain drugs; factitial alterations;
benign and malignant neoplasms; and changes
in the oral tissues secondary to systemic diseases.

Foremost in consideration are the changes in
the oral cavity occurring as part of generalized
disease states. The mucous membranes, as well
as the skin, often reflect changes in systemic dis-
eases that, in some instances, are characteristic
and pathognomonic in themselves and, in other
instances, are compatible with the general re-
action.

GRANULOMAS

The differential diagnosis of granulomatous le-
sions of the mouth still includes tuberculosis,
syphilis, and malignant tumors. In the presence
of a clinical picture of a nonspecific granuloma
in which the histologic picture is not that of
malignancy, a portion of the tissue removed for
biopsy should be subjected to culture and ani-
mal inoculation for bacterial and mycotic or-
ganisms.

T uberculosis. A high index of suspicion should
be maintained in patients with oral lesions whose
histories reveal previous active tuberculosis and
who may present the symptoms of fever, loss of
weight, and cough together with a positive
Mantoux reaction and an increased ervthrocytic
sedimentation rate. Tuberculosis cutis orificialis
is that form of tuberculosis in and about the bodv
orifices found in association with active svstemic
tuberculosis. The clinical picture of the oral
lesions is nonspecific (figure 1). A small fissure
or ulcer in the tongue of a patient with a back-
ground of active tuberculosis should make one
bend every effort to establish the cause as tuber-
culosis. Recently, the cases of a few such pa-

336

THE JOURNAL-LANCET

Fig. 1. Tuberculous granuiffima of the gum proved bac-
teriologically.

tients with very minimal ulcers of the tongue
were diagnosed by recovering Mycobacterium
tuberculosis by culture and animal inoculation.

Syphilis. Almost nonexistent today, syphilis
still must be considered in the differential diag-
nosis of granulomas of the oral cavity. Difficulty
arises in the diagnosis because of failure to con-
sider the possibility of the disease being present
at all.2 In patients with gummas, a history of
possible syphilis is sometimes of help, but sero-
logic tests for syphilis and laboratory studies on
cerebrospinal fluid are necessary adjuvants for
proper evaluation of the patient. The granuloma
of syphilitic origin does not present character-
istics that identify its origin. Unlike the situation
in tuberculosis, in which the cause can be con-
firmed by cultural technics, there are no lab-
oratory aids that permit the positive identifica-
tion of such lesions. The histopathologic picture
is suggestive of syphilis when a granuloma pre-
sents an infiltrate rich in plasma cells, particu-
larly when their location is circumvascular.

The therapeutic test with penicillin given in
adequate doses over a sufficiently' long period
brings about beginning resolution of most syphi-
litic granulomas within ten days. The rapid re-
sponse of the patient with syphilis to this anti-
biotic has necessitated a new standard of treat-
ment for the disease. These destructive syphilitic
granulomas of the oral cavity heal with amaz-
ingly little residual deformity. A small perfora-
tion of the palate is often the only vestige of a
large gumma that has been treated properly.

Syphilis at times is accompanied by interstitial
glossitis. As a residuum of that process, the
tongue may become atrophic, thinned, and ta-
pered and present a vivid magenta hue. These
atrophic changes may or may not be associated

with leukoplakia. These composite alterations
in the tongue are characteristic of involuted
syphilitic glossitis; when they are present, the
diagnosis of syphilis usually can be confirmed by
appropriate laboratory tests.

Fungous diseases. Among the other diseases
of known cause that produce mucous-membrane
lesions are those resulting from fungi. Exem-
plary in this regard, although rare, is South
American blastomycosis,3 which frequently
begins with a nonspecific, painful granuloma of
the mouth and oropharynx. Progression of the
disease results in difficulty in eating and swal-
lowing, and the patient’s nutrition is affected.
Granulomatous cutaneous lesions are also pres-
ent, and, from these as well as the oral lesions,
the causative organism, namely, Blastomyces
brasiliensis, can be recovered by appropriate
methods. The histopathologic appearance of the
involved regions is not specific.

Histoplasmosis is another of the systemic my-
coses in which oral lesions are relatively com-
mon. In fact, cases have been reported in which
ulcers of the tongue have been the presenting
symptom. The usual findings, however, are those
of intermittent fever, loss of weight, weakness,
anemia, and leukopenia. The patient also may
display hepatosplenomegaly; generalized lym-
phadenopathy; and nasal, oral, and pharyngeal
ulceration.

In a few patients with histoplasmosis who
were recently studied, unilateral “perleche” was
one of the findings noted on initial examination.
This unilateral involvement is in contrast to the
symmetric process seen in patients with ill-fitting
dentures whose loss of saliva at the angles of
the lips provides a culture medium for micro-
cocci, streptococci, or Candida. The specificity
of these unilateral fissures at the angles of the
mouth was demonstrated by culturing from them
the causative organism, namely, Histoplasma
capsulatum. Nondescript granulomas of the oro-
pharynx may be mistaken for lymphoid hyper-
plasia, but their true nature can be proved by
biopsy and culture.

Local moniliasis, as a part of systemic moni-
liasis or candidiasis, produces superficial ulcers
and a white membrane in association with ir-
regularity and rugosity of the oral tissues. Be-
cause of the resemblance of moniliasis, at times,
to the oral lesions of systemic lupus ervthema-
tosus, these two conditions will be discussed
together in a subsequent section.

METABOLIC DISEASES

Macroglossia in amyloidosis and myxedema. In
systematized amyloidosis, indurated macroglos-

AUGUST 1958

337

Fig. 2.

Indurated

macroglossia

pathognomonic

of primary

systematized

amyloidosis.

sia is pathognomonic.4 In this disease, amyloid,
a mucoprotein, is deposited in the musculature
of the vessels and in many of the organs, par-
ticularly in the muscles of the intestine and the
heart. Because of amyloid infiltration, the tongue
may become enormously enlarged, a change that
may be the first sign of the disease (figure 2).
Associated cutaneous lesions may consist of
chamois-colored, translucent papules that can
occur anywhere on the body but primarily about
the face. Rather pronounced erythema and
edema of the hands and forearms may be noted.
Similar deposition of amyloid in the vessels re-
sults in their friability. Thus, ecchymosis of the
tissues may develop even with minor trauma.
Multiple myeloma is often an associated disease,
the presence of which can be proved by finding
myeloma cells in the bone marrow and peri-
pheral blood and by evidence of Bence Jones
proteinuria.

Macroglossia also is seen in generalized myxe-
dema, but the tongue in this instance lacks the
induration of tissue noted in systematized amy-
loidosis. In patients with generalized myxedema,
the skin becomes dry, thickened, rough, scaly,
and somewhat waxy yellow. The hair becomes
dull, coarse, thin, and rather unmanageable be-
cause of these changes. The enlargement of the
tongue makes it difficult to speak. At times, the
same edematous quality affecting the pharynx
produces huskiness of the voice.

Xanthomas. The metabolism of fat and its role
in the production of cardiovascular disease have
been the subject of recent investigations. The
xanthomas have been long associated with the
problem of altered levels of blood lipids. Their
presence in some patients in conjunction with
cardiovascular disease, diabetes mellitus, dia-
betes insipidus, and biliary cirrhosis has been
recognized for a long time. In some patients,

these cutaneous xanthomas are accompanied by
mucosal deposition of the same fatty material,
which imparts an orange-brown hue to the tis-
sues involved. The color of the gum tissue in
this disease is unique.

Addison's disease. Generalized pigmentation
of the skin and macular hyperpigmentation of
the mucosa are common in Addison’s disease
(figure 3 a). The general complaints of weak-
ness, easy fatigability, and loss of weight in
association with the laboratory findings of hypo-
tension with a small pulse pressure and de-
creased urinary excretion of 17-ketosteroids are
the paramount criteria in diagnosis. The brown-
ish pigmentation of the skin, most prominent in
the folds and those areas exposed to the sun,
together with mottled pigmentation of the lips
and buccal mucosa, adds confirmatory evidence.

Peutz-Jeghers syndrome. In contrast, however,
macular hyperpigmentation of the lips and buc-
cal mucosa unassociated with generalized hyper-
pigmentation may be the clue to the diagnosis
of Peutz-Jeghers syndrome, namely, oral pig-
mentation with intestinal polyposis (figure 3b).
Discrete zones of macular pigmentation also
may occur about the face, the root of the nose,
the eyelids, and the tips of the digits. The entire
gastrointestinal tract of these patients must be
studied, as polyps may be found in any of its
parts. Recent study indicates that malignant
degeneration of the polyps does not occur in this
form of polyposis.5

The blue pigmentation of the oral mucosa seen
in patients taking quinacrine hydrochloride
(Atabrine) is hardly to be confused with the
black macular pigmentation seen in either Addi-
son's disease or the Peutz-Jeghers syndrome.

HEREDITARY DEFECTS

Recklinghausen's disease. The tumors in neuro-
fibromatosis, or Recklinghausen’s disease, most
commonly involve the skin but are present in
other tissues, including the tongue (figure 3c).
The cutaneous lesions consist of variously sized,
red to violaceous, soft tumors that can involve
any portion of the integument. Brownish macular
zones of hyperpigmentation (cafe au lait spots)
are part of this hereditary syndrome, which in-
cludes rather low physical and mental ability in
many members of a family. These lesions are
rarely localized solely on the tongue. The in-
dividual tumors in this location are firm. Unless
excessive growth interferes with articulation and
nutrition, treatment is not required.

Telangiectasia. Multiple telangiectatic lesions
occur on the face, palate, tongue, nasal septum,
and body of patients with familial or hereditary

338

THE JOURNAL-LANCET

Fiff. 3 a. Pigmented macules on lips and gums
in Addison’s disease. (/;). Pigmented macules
on lips and buccal mucosa led to diagnosis of
intestinal polyposis in this case of Peutz-feg-
hers syndrome, (c). Lingual neurofibromas in
Recklinghausen’s disease, (d). Oral lesions in
hereditary hemorrhagic telangiectasia.

hemorrhagic telangiectasia, or Rendu-Osler-
Weber disease (figure 3 d). At times, conglomer-
ate capillary tufts or small angiomas are present
with the telangiectasis, presenting a small tumor
formation much like senile ectasia. Rupture of
these vascular lesions residts in hemorrhage that
often causes anemia. Hemorrhage can be sudden
and sufficiently severe to cause a shocklike state
and death. The disease is found in and trans-
mitted by both sexes. The possible presence of
pulmonary arteriovenous fistulas in patients with
hereditary hemorrhagic telangiectasia should not
be overlooked.

POLYOSTOTIC FIBROUS DYSPLASIA

This is a disease in which the central portions of
bones are replaced by connective tissue, which
grows and expands the bones. Osseous spicules
subsequently develop in this connective-tissue
stroma. The combination of fibrous dysplasia of
bone, macular pigmentation, and sexual precoc-
ity in women, in association with disturbances
of hormonal balance and growth, is known as
Albright's syndrome. Peculiarly enough, the
maxilla is frequently involved early, and, thus,
enlargement of one maxilla may give a clue to
the early diagnosis of this disease.

LUPUS ERYTHEMATOSUS

Since the introduction of the L. E. test of
Hargraves for lupus erythematosus, considerable

attention has been focused on this entity. The
discoid variety of this disease— cutaneous lesions
without general systemic complaint— is seen with
regularity. Systemic lupus erythematosus, how-
ever, is a rare disease characterized by recurrent
arthralgia, fever, and fatigue, particularly affect-
ing young women of fair complexion. In the past,
a butterfly eruption over the face was considered
pathognomonic, but today the aforementioned
three symptoms associated with polyserositis,
recurrent infection, Raynaud’s phenomenon, and
nonspecific cutaneous eruptions, such as urti-
caria, purpura, and erythema multiforme, key-
note the diagnosis. Patients who have systemic
lupus erythematosus are frequently so ill that
the physician is unconcerned with the presence
of oral lesions. Hyperkeratosis of the mucous
membrane presents itself clinically as a white
sheen in the involved zones. Some rugosity of
the tissues and superficial erosions and ulcers
may be present. The oral lesions are essentially
asymptomatic, except when ulceration is present,
and are not diagnostic by themselves. Together
with any cutaneous lesions and symptoms, they
resolve as appropriate therapy is administered.

Leukoplakia, moniliasis, lupus erythematosus,
and lichen planus present lesions of the mucous
membrane that at times are indistinguishable
clinically. The last two conditions may present
collateral evidence of the disease on the skin
that makes the diagnosis apparent. The causa-

AUGUST 1958

339

tive organism, Candida albicans, can be cultured
from the lesions of patients with moniliasis.

Leukoplakia is a hyperkeratotic reaction of
mucous membrances that appears to be precipi-
tated by constant trauma of various types. The
role of syphilis and interstitial glossitis in the
production of leukoplakia already has been men-
tioned. White, spongy nevus of the oral cavity
is rarely confused with any of these lesions be-
cause of its extensive involvement of the oral
tissues and the history of its presence in even
young members of the family.

BLISTERING ERUPTIONS

When generalized blistering eruptions are seen,
the differential diagnosis is primarily between
dermatitis herpetiformis, erythema multiforme,
and the various forms of pemphigus. Although
exceptions occur, dermatitis herpetiformis rarely
has associated oral lesions. On the other hand,
erythema multiforme and pemphigus frequently
present lesions of the mucous membrane as a
part of their morphologic picture.

Although it has a rather characteristic mor-
phologic picture, erythema multiforme does not
denote an etiologic entity. Rather, it is seen as
part of the systemic reaction in a variety of con-
ditions: namely, septic sore throat, arthritis, and
drug reactions. As the name of the disease im-
plies, the cutaneous lesions are characterized by
multiform, erythematous papules and plaques.
Its differentiation from urticaria is sometimes
difficult, but the presence of iris lesions, formed
by concentric alternating zones of involved and
uninvolved tissue with a bullous reaction in the
center, categorizes this disease as erythema mul-
tiforme. When blisters are present in the oral
lesion, they are hemorrhagic in nature in the
majority of cases. As a rule, however, the oral
lesions soon rupture, and nonspecific ulcers are
formed that are not diagnostic. Characteristic
cutaneous lesions must be present in order to
make the proper diagnosis.

Since the introduction of the therapeutic use
of corticotropins and corticosteroids, the course
of pemphigus has been tempered, but it still has
a grave prognosis. The clinical picture in this
disease is characterized by bullae of various sizes
on the skin, with or without an urticarial com-
ponent. As the disease progresses, severe sys-
temic repercussions are noted, with debility and
decline in the general health.

Blisters frequently develop in the mouth. The
individual oral lesions may hang as large blebs
like stalactites from the hard and soft palate.
Rupture of these lesions produces superficial
ulcers; the process at times becomes more se-

vere, with ragged, irregular ulcers of the oral
cavity supervening.

The cutaneous lesions of erythema multiforme
and pemphigus may be differentiated histolo-
gically, with epidermal-dermal separation de-
noting the former and intra-epidermal disinte-
gration characterizing the latter. Aeantholysis,
which is the separation of individual epidermal
cells from the neighboring cells through rupture
of the intercellular bridges and associated de-
generative changes of the nucleus and cvtoplasm,
characterizes pemphigus.

One of the diseases of viral origin that may
affect the oral cavity is herpes zoster, which is
caused by a neurotropic virus. This is a blister-
ing eruption associated with severe pain that
takes a segmental distribution along the course
of nerve trunks. The involvement is almost al-
ways unilateral, particularly when cranial nerves
are affected. Involvement of various branches of
the fifth cranial nerve is a frequent clinical find-
ing. If the dental branch of the middle division
of this nerve is involved, unilateral blistering of
the hard and soft palate is seen.

HEMATOLOGIC DISEASES

The oral changes in patients with pernicious
anemia have been recognized for many years.
The laboratory findings include achlorhydria,
hypersegmented neutrophils, and macrocytic
anemia. Weakness, gastrointestinal disturbances,
and neurologic complaints are frequently part
of the clinical picture. Changes in the oral
mucosa are suggestive of the disease; these con-
sist of a red, smooth, atrophic tongue produced
in part by recurrent blistering and disappearance
of the papillae. Soreness and burning are present
in a large proportion of these patients.

A hemorrhagic tendency of the mucous mem-
branes and thrombosis of the skin with subse-
quent ulceration are among the signs that char-
acterize the clinical picture of polycythemia
vera (figure 4n). The basic problem is that of
an excessive number of erythrocytes independ-
ent of a physiologic increase in number due to
exposure to high altitudes. The disease affects
men and women with equal frequency, usually
during the middle decades of life. The increase
in erythrocytes can account for most of the
cutaneous features of the disease, which include
a plethoric facies and cyanosis of the acral areas
(including ears and hands), together with head-
ache, tinnitus, cerebral thrombosis, and phlebitis.
Because of the superficial position of the vascular
bed in the mouth, hemorrhage frequently occurs.

Multiple myeloma represents a neoplastic
process in which overgrowth of myeloma cells

340

THE JOURNAL-LANCET

Fig. 4a. Hemorrhagic oral lesions
in polycythemia vera. (b). Tumor
of palate in multiple myeloma.

occurs in various tissues and organs. Hemo-
cvtologic and bone-marrow studies for myeloma
cells and urinary studies for Bence Jones protein
are necessary adjuncts to diagnosis. Tumors are
rarely seen in the oral cavity as a part of the
clinical picture in this disease, but thev do occur
from time to time (figure 41)).

As might be anticipated in thrombocytopenic
purpura, hemorrhagic manifestations are com-
mon, with oral involvement being the usual find-
ing in such patients. The clinical picture is
usually that of punctate purpura progressing to
ecchymosis and finally to gross bleeding from
the oral tissues, particularly the gums. It has
been recognized for a long time that even the
slightest trauma may initiate this sequence of
events. On the other hand, they may develop
spontaneously without apparent antecedent
trauma.

Agranulocytosis and aplasia of the bone mar-
row produce the same clinical picture regard-
less of the cause. Exposure to various chemicals,
the ingestion of certain drugs, or total body ir-
radiation may be responsible. With decrease in
the number of granulocytes in the blood, ample
opportunity for infection occurs, so that bac-
teria, which are commonly present in great
numbers within the oral cavity, multiply and
flourish luxuriantly. One of the earliest signs of
granulocytopenia is the development of white
plaques on the mucous membranes that repre-
sent foci of bacteria. Gingivitis, ulceration, and
necrosis, with frank bleeding from the tissues of
the oral cavity, occur later. These changes are
associated with the systemic signs of overwhelm-
ing infection, melena, a shocklike state, and
often death.

Splenic neutropenia is a disease in which the
cyclic destruction of neutrophils by the spleen
occurs at irregular intervals. When a period of
neutropenia exists, marginal gingivitis, ulcers,
and recurrent infections of the mouth are likely
to be present.

Infectious mononucleosis is recognized pri-
marily by the constitutional symptoms of fever,
malaise, and general lvmphadenopathy, particu-
larly in the cervical region, together with the
presence of abnormal lymphocytes in the blood
and an increased titer of heterophilic antibodies
in the serum. Oral lesions are not uncommon in
this disease, consisting, at times, of general in-
flammation of the oral tissues with soreness and,
on occasion, edema of the uvula and, less fre-
quently, of ulcers in the tonsillar region. Char-
acteristic, when present, is a petechial eruption
lasting for two to four days on the roof of the
mouth at the junction of the hard and soft palate.

In the past, reference was made to lymphatic
leukemia and myeloid leukemia as entities. Re-
cent nosology favors a broader concept and con-
siders leukemia itself as part of an entire clinical
picture. Classification into two groups clarifies
the problem by designating as lymphoma those
malignant tumors which usually arise from mul-
tiple foci in the lymphoid reticular system, with
lymphatic leukemia being associated with only
a portion of these tumors, and by designating as
myelosis those malignant tumors usually arising
from multiple foci in the myeloid system and
with which leukemia, myeloid in tvpe, invari-
ably is associated.

Cutaneous and mucous membrane manifesta-
tions of the leukemic states may he specific
(metastasis from within) or nonspecific, such as
erythema, purpura, and ulceration. Differenti-
ation of these entities based on the clinical ap-
pearance of oral and cutaneous lesions is impos-
sible. Hemocytologic studies of peripheral blood
and bone marrow, as well as biopsy of lymph
nodes and skin, often are required for definite
diagnosis.

The lesions of the oral mucous membrane in
the leukemic state are characterized by red
spongy gums that tend to bleed easily even with
minimal trauma (figure 5). Superficial ulcers
and necrotic lesions may be produced at times.

AUGUST 1958

341

Fig. 5. Red,
spongy, hemor-
rhagic' gums in
monocytic
leukemia.

Purpuric, hemorrhagic, and bullous lesions are
relatively common. Purpura, as an isolated find-
ing, is nonspecific in nature and is found as a
terminal toxic manifestation in either lymphoma
or myelosis. Lesions of the mucous membrane
consisting of swelling and ulceration of the gums
apparently occur earlier in the course of the

disease in patients with monocytic leukemia. As
a group, however, oral lesions are found more
frequently in chronic lymphatic leukemia. As
emphasized previously, the histopathologic pic-
ture may be nonspecific or the gingivitis and
ulceration may be specific, as determined by
further study of histologic preparations.

SUMMARY

An attempt has been made to emphasize the im-
portance of a meticulous examination of the oral
cavity as an aid in the diagnosis of systemic dis-
eases. In some instances, changes in the oral
cavity may be pathognomonic, whereas, in other
cases, they may only indicate the direction in
which laboratory evaluation should proceed in
order to establish the diagnosis.

REFERENCES

1. Editorial: The oral cavity and disease, J.A.M.A. 165:159,

1957.

2. Perry, H. O., Kierland, R. R., and Magath, T. B.: Clinical
problem of syphilis today. Minnesota Med. 39:717-722; 736,
1956.

3. Perry, H. O., Weed, L. A., and Kierland, R. R.: South

American blastomycosis; report of case and review of labora-
tory features. A.M.A. Arch. Dermat. & Syph. 70:477, 1954.

4. Brunsting, L. A., and Macdonald, I. D.: Primary system-

atized amyloidosis with macroglossia; syndrome related to
Bence-Jones proteinuria and myeloma. J. Invest. Dermat. 8:
145, 1947.

5. Bartholomew, L. G., Dahlin, D. C., and Waugh, J. M.:
Intestinal polyposis associated with mucocutaneous melanin
pigmentation ( Peutz-Jeghers syndrome): Review of literature
and report of 6 cases with special reference to pathologic find-
ings. Gastroenterology 32:434, 1957.

Transient cutaneous flushing is characteristic of patients with functioning
carcinoid, although cardiac, respiratory, and gastrointestinal symptoms may lie
lacking. The Hush may last as long as thirty minutes but usually persists less
than ten. The process may be repeated many times a day.

The face is most frequently and severely affected, but the entire torso and
arms and legs may be involved. During a Hush, the face and upper part of
the body may feel hot, stiH, and swollen. Paresthesias of the fingers may be
noted. The scleras are reddened. Cyanosis may appear in spots in the area
of flushing. The central portion of the Hush subsides first; the fading extends
peripherally and leaves gyrate and serpiginous patterns.

As flushing becomes chronic, telangiectasia is evident and cyanosis is per-
sistent. The patient ultimately appears plethoric, lmt the erythrocyte and leu-
kocyte counts, cell volume, and hemoglobin concentration remain normal.
Hypotension frequently occurs a few seconds after the appearance ol a flush
and may result in syncope and, in some instances, even shock.

Flush may occur spontaneously or be precipitated by ingestion ol food or
alcohol, mechanical stimuli, emotional upsets, sudden temperature changes,
or evacuation of the bowel.

Histologically, the affected skin shows dilatation and congestion of veins
and capillaries; occasional thickening of vessel walls, including arterioles;
edema; and chronic inflammation.

Robert R. Kierland, M.D., William G. Sauer, M.D., and William II. Dealing, M.D., Mayo
Clinic and Foundation, Rochester. Arch. Dermat. 77:86, 1958.

342

THE JOURNAL-LANCET

Sex Hormone Support for
the Castrate or Senescent Woman

TACE with Androgen: A Review of Experience

G. WILSON HUNTER, M.D., JOHN S. CILLAM, M.D.,
C. B. DARNER, M.D., and GEORGE THOMPSON, M.D.

Fargo, North Dakota

"O teroid replacement technics in no sense
represent a panacea for the problem of
aging. There is no evidence of increased long-
evity for those patients under combined steroid
influence. However, in the majority of treated
patients, there is significant physical and men-
tal resurgence of power potential.’’1

It is hardly necessary in this enlightened year
to restate or defend the rationale of sex hor-
mone replacement in the aging. The constantly
improving methods of measuring urinary steroid
excretion have now given factual support to
earlier hypotheses regarding probable declines
in levels of certain, if not .all, steroid hormones
with advancing age. Evidence is now irrefutable
that the output of ovarian and testicular hor-
mones declines much more rapidly and to lower
levels than does that of the adrenocortical ster-
oids. In fact, relatively short functional life of
the gonads — from puberty to the climacteric —
as compared with that of all other endocrine
glands has led Masters2 to describe the exist-
ence of a “third sex” or “neutral gender.”

The physical and emotional symptoms which
accompany the decline in gonad function are
frequently of such magnitude that the individ-
ual is motivated to seek relief. A large segment
of patients comprising the average gynecologic
practice consists of postmenopausal women,
many of whom have experienced relative failure
of relief from the heavily promoted drugstore
panaceas. Women are certainly far more sub-
ject than men to stress resulting from these
changes, since ovarian function ordinarily is
depressed abruptly at the menopause, while
testicular function usually declines at a slower
rate over a longer period of time. Thus, men are

G. WILSON HUNTER, JOHN S. GILLAM, C. B. DARNER,

and george Thompson are with the Department of
Obstetrics and Gynecology at the Fargo Clinic and
on the staff of St. Luke’s Hospital, Fargo.

granted by their Maker a reasonable period of
time for adaptation to the “neutral gender”
status.

Although one would assume from theoretic
considerations that simple replacement of de-
clined ovarian steroid levels in the female should
suffice to halt and reverse the changes, we have
learned through much trial and error that such
treatment has certain disadvantages. Continuous
support with estrogens alone in the female cli-
macteric leads frequently to endometrial hyper-
plasia and breakthrough bleeding. Cyclic treat-
ment with estrogens or with estrogens and pro-
gesterone results in periodic endometrial slough.
While such vaginal bleeding or “false menses "
is in itself not necessarily pathologic, it is far
better to use a treatment, if available, which
accomplishes the desired end result without sub-
stituting one type of worry for another. Com-
bined therapy with properly balanced amounts
of estrogen and androgen is now well estab-
lished as fulfilling the essential requirements for
physiologic steroid replacement in these patients.

Reduced to the simplest possible hypothesis,
the beneficial extragonadal effects of these hor-
mones are considered to be due to the ability
of estrogens to increase permeability of the cell
membrane and the tendency of androgen to pro-
mote storage of protein. Thus, there exist mu-
tually enhancing metabolic and anabolic activ-
ities of the two types of hormones which may
be controlled through their concomitant admin-
istration in proper proportion. The beneficial
results of combination therapy upon calcium and
phosphorus metabolism, promotion of protein
matrix sparing, formation in osteoporotic bone
and in muscle, and improvement in the tone and
integrity of the vascular system may all be re-
lated to increased permeability of the cell mem-
brane and enhanced storage of protein. In ad-
dition, there appears to be a “mutually antag-
onizing” activity of the two steroids in terms of

AUGUST 1958

343

their effects upon the sex organs. For example,
the tendency of estrogens alone to stimulate en-
dometrial hyperplasia is satisfactorily blocked
by androgen added in appropriate amount. This
eliminates the principal disadvantage of therapy
which subjects the endometrium to cyclic change
and adds the further advantage of protein-spar-
ing activity.

There are now well over 50 prescription phar-
maceuticals available, which contain a variety
of combinations of estrogenic and androgenic
substances for both oral and parenteral admin-
istration. The physician’s task of choosing a
medication for his patient has become most dif-
ficult. In many instances, it is possible that the
choice of preparation depends principally upon
the persuasiveness of the representative of the
pharmaceutical manufacturer concerned, the ef-
fectiveness of the manufacturer’s advertising
program, or the reputation of the company.
Perhaps such factors were involved in our choice
of TACE with Androgen for the treatment of
those patients in whom we thought combination
steroids were indicated. However, as we report-
ed in 1954, 3 our experience with TACE in the
management of symptoms associated with the
menopause had always been most gratifying.
Because of the ability of TACE to become stored
in body fat, resulting in a “depot" effect, and
the absence of annoying side effects, especially
nausea, following its administration, this unique
and orally effective pro-estrogen enables the
menopausal patient to adapt easily to her ulti-
mate postmenopausal state.

Combined steroid therapy should be minimal
for those patients who continue in the postmeno-
pause to require such support. The combination
capsule of TACE with Androgen contains 6 mg.
of chlorotrianisene and 2.5 mg. of orally active
methyltestosterone. The structural formulas for
these compounds are shown in figure 1. Neither
of the hormones is provided in sufficient quantity
to cause undue feminizing or virilizing effects
after prolonged daily administration of a single
capsule. In fact, both are considered to be in
a “mutually neutralizing” ratio when larger doses
infrequently become necessary. Experience sup-
ports our earlier belief that most patients obtain
optimum benefit in terms of symptomatic relief
as well as metabolic and anabolic support from
an average dose of 1 capsule daily.

MATERIAL AND METHODS

Following the preliminary phase of the present
study, we reported4 consistently good results in
the management of subjective symptoms and ob-
jective findings in 34 selected postmenopausal

OH

Methyltestosterone

Fig. I. Structural formula of chlorotrianisene and meth-
yltestosterone.

patients who were treated initially with 2 cap-
sules daily for ten days, after which they were
maintained with a dose of 1 capsule daily. Of
the 34 patients, 27 had undergone natural meno-
pause, and the remaining 7 had been castrated
either surgically or by irradiation.

It has now become possible to review con-
tinued experience with the original group of
patients and to extend observations to include
a total of 92 patients who have been treated with
TACE with Androgen for similar complaints.
Of these, 67 patients are past the natural meno-
pause, 24 have been castrated surgically, and 1
patient was castrated by irradiation. The range
in age of the group is 29 to 71 years, and most
of the patients are 45 or older. All are ambula-
tory, white, private patients who have been ob-
served for varying periods of time up to two
years. All patients complained of one or more
symptoms of a complex which we have chosen
to call the “postmenopausal syndrome.” These
complaints are listed in order of frequency in
table 1.

Of the 92 patients under study, 22 had re-
ceived previous drug therapy for their symp-
toms, consisting of estrogens alone, estrogen-
androgen combinations, or sedation. They were
selected for this study because of inadequate
symptomatic control by previous medications or
the occurrence of side effects.

All patients in this series were given 2 cap-
sules of TACE with Androgen daily at the out-
set of treatment. After 10 days, the dose was
reduced empirically to 1 capsule daily and gen-
erally maintained at this level. Six of the pa-

344

THE JOURNAL-LANCET

TABLE 2

TABLE 1

EFFECTIVENESS OF TACE WITH ANDROGEN
IN CONTROL OF SYMPTOMS OF THE POSTMENOPAUSAL
SYNDROME IN 92 PATIENTS

OBJECTIVE RESULTS OF TREATMENT WITH TACE
WITH ANDROGEN IN 92 PATIENTS WITH FOSTMENOPAUSAL
SYNDROME

Number

Complete

Partial

No

Treatment

1

Symptoms

complaining

relief

relief

relief

Number of

Treatment

partially

T reatment

—

Objective finding

patients

effective

effective

ineffective

Hot flushes

52

47

4

i

Urinary

28

19

6

3

Senile vaginitis

44

36

6

2

Nervousness

26

24

2

0

Osteoporosis

8

5

1

2

Depressed libido

15

14

0

1

Vaginal dryness

6

5

1

0

Irritability

13

12

1

0

Hair and skin

Dyspareunia

11

8

3

0

changes

2

1

1

0

Insomnia

10

10

0

0

Vulvar irritation

i

1

0

0

Backache

8

5

1

2

Tight introitus

i

1

0

0

Depression
Fatigue
Headache
Vertigo

Pruritus vulvae

Palpitation

Mastalgia

M uscle pains

Paresthesias

Joint pains

Anxiety

tients voluntarily have taken the medication on
an irregularly intermittent schedule. Because of
the complaint of “pelvic pressure” in 1 patient,
the dose was reduced to 1 capsule every other
day, resulting in relief of this symptom but only
partial relief of her stress incontinence and pru-
ritus vulvae. Three other patients obtained only
partial symptomatic relief when 1 capsule was
given daily but were completely relieved when
the dose was increased to 2 capsules a day.

RESULTS

The control of subjective complaints among the
92 patients in the series ( table 1 ) has been
highly gratifying to us and to the patients.
Only 1 of the 52 patients who complained of
hot flushes was not relieved. One of the 15
patients with loss of libido and 1 of the 4 pa-
tients complaining of fatigue failed to obtain
some measure of relief. Of even greater interest
and significance is the fact that relief failed to
occur in only 3 of the 28 patients who com-
plained of urinary symptoms, such as frequency,
dysuria, and urge and stress incontinence asso-
ciated with senile vaginitis. In this group, no
abnormalities were detected upon urinalysis, in-
dicating that the symptoms were not due to
chronic cystitis or lower urinary tract disease.
The improvement following endocrine therapy
is indicative of positive protein anabolic effects

with subsequent improvement in muscle tonus.
No other failures of symptomatic relief were re-
ported. Complete relief occurred in most patients
with virtually all types of complaints. All pa-
tients obtained some degree of relief.

Improvement in objective findings was noted
in the majority of instances in which such find-
ings were apparent. Table 2 is an outline of this
experience. Except in the cases of osteoporosis,
objective improvement was graded by direct
observation. The most frequent complaint in
senile osteoporosis is back pain, although pain
may sometimes occur in association with osteo-
porotic areas of bone other than the spine even
in the absence of pathologic fracture. All of our
8 cases of roentgenologically proved senile osteo-
porosis had subjective complaints related to their
lesions. Complete relief in 5 of these cases, par-
tial relief in 1, and no relief in 2 are reflections
only of the symptomatic improvement (or lack
of it) in these patients.

Except for 1 patient who complained of a
sensation of increased pelvic pressure when she
was given 1 capsule daily, there have been no
significant side effects attributable to TACE with
Androgen in this series. Relief in this patient
was achieved by reducing the dose to 1 capsule
every other day. It may be stated categorically
that the dose of TACE with Androgen seldom
needs to be altered from the average mainte-
nance level of 1 capsule per day. Younger wom-
en who have been castrated surgically may re-
quire 2 or even 3 capsules daily for adequate
symptomatic control. Conversely, it has been
possible in several instances to reduce the dose
in elderly women with senile vaginitis to 1 cap-
sule every other day. We have had only 1 case
of postmenopausal spotting, which occurred in
a 53-year-old woman who had been receiving
TACE with Androgen. Diagnostic dilatation and
curettage in this instance revealed the presence

AUGUST 1958

345

of endometrial polyposis, and, therefore, it was
considered advisable to discontinue hormone
treatment.

During the period of this study, we have also
been prescribing TACE with Androgen to pro-
mote vascularity and enhance healing for all
patients with senescent vaginal changes who
have been treated surgically. These patients are
not included in the present tabulation because
it has been assumed that many of their symp-
toms were probably related to the presenting
pathologic changes, such as urethrocele, cys-
tocele, and rectocele. This group of patients has
responded more than satisfactorily to TACE
with Androgen treatment in the usual dose of
1 capsule daily. Many such patients who are
treated surgically for these conditions find that,
although they are improved symptomatically, in-
tercourse is frequently difficult and painful. In
none of the patients of this series has postopera-
tive dyspareunia been a complaint. The subjec-
tive response of this group has been most grati-
fving.

REFEl

1. Masters, W. H.: Endocrine therapy in the aging individual.

Obst. & Gynec. 8:61, 1956.

2. Masters, W. H.: Rationale of sex steroid replacement in the

“neutral gender/* J. Am. Geriatrics Soc. 3:389, 1955.

3. Gillani, J. S., Hunter, G. W., and Darner, C. B.: Prelim-

SUMMARY AND CONCLUSIONS

Ideally, a useful estrogen-androgen preparation
for the management of the postmenopausal syn-
drome should be orally effective. It should con-
tain only sufficient quantities of the two hor-
mones to provide the desired metabolic support
or replacement with mutual neutralization of
the potentially undesirable genital effects. These
qualities have been most nearly approached by
TACE with Androgen, which was studied clin-
ically during a two-year period in 92 private
patients with a variety of postmenopausal symp-
toms. Subjective and objective improvement
have been noted in all types of complaints and
findings associated with the syndrome and in the
great majority of cases. No serious side effects
have been encountered, and none of the patients
has been unable to tolerate the medication be-
cause of nausea and vomiting. The maintenance
dose of 1 capsule daily is usually preceded ini-
tially by 1 capsule twice daily for ten days.

TACE and TACE with Androgen were supplied for this
study hv The Wm. S. Merrell Co., Cincinnati.

ENCES

inary experience in treatment of menopause with TACE, a new
type of estrogen. J. Clin. Endocrinol. 14:272, 1954.

4. Hunter, G. W., Gillam, J. S., Darner, C. B., and Thomp-
son, G.: TACE with Androgen in treatment of women in post-
menopause and senescent years. Journal-Lancet 77:150, 1957.

Surgery may be performed advantageously during the puerperium for um-
bilical hernias, perineal tears, fistulas, rectoceles, ovarian cysts, and intestinal
complications. Healing is very efficient during this period, and many tissues,
hypertrophied by pregnancy, are conveniently lax for easy dissection and have
a rich blood supply.

The immediate postpartum period is a particularly ideal time for repair
of umbilical hernias because strangulation may occur after labor and because
the abdominal wall is slack.

D. H. Blakey, M.D., University of Sheffield, England. Lancet 2:1312, 1957.

Most of the toxic phenomena of pregnancy can be relieved by a diet high
in salt. For patients with early toxemia, the larger the amount of salt, the
faster and more complete the recovery. All of 20 women with early toxemia
were benefited by extra salt in the diet. Symptoms recurred when additions
were not continued until the time of delivery. Of 1,019 women instructed to
increase sodium chloride intake, 38 had toxemia; of 1,000 women who de-
creased salt consumption, 97 had toxemia. The incidence of edema, perinatal
death, and hemorrhage during pregnancy and ante partum was also lower in
women taking extra salt.

Margaret Robinson, M.D., Derby, England. Lancet 1:178, 1958.

346

THE JOURNAL-LANCET

Postoperative Medical Emergencies

DONALD LAMB, M.D.

St. Paul, Minnesota

The purpose of this paper is twofold: first,
to acquaint the consulting medical residents
with certain procedures and drugs used in sur-
gery which predispose the patient to postopera-
tive complications for which these physicians
are likely to he called on for consultation; sec-
ond, to provide in general a review of the lit-
erature which will facilitate reading on any op-
erative medical problem encountered.

Moore1 describes the normal postoperative
pattern of response as a transient rise in tem-
perature, increase in pulse rate, transient de-
crease in urinary output, negative nitrogen bal-
ance for three to seven days changing to posi-
tive nitrogen balance, excessive potassium loss
for two to five days, decreased sodium loss for
two to three days, increased fat oxidation, and
increased secretion from the adrenal cortex.
These conditions require treatment only when
aggravated by complications.

EXTRARENAL FLUID AND ELECTROLYTE LOSS

When confronted with the correction of fluid
and electrolyte loss postoperatively, there is no
substitute for accurate collection and calcula-
tion of specific losses, after which an estimation
of fluid and electrolytes is necessary. The accom-
panying graph lists the “average” losses of elec-
trolytes from specific drainage sites in the nor-
mal functioning gut. These values are means,
and they have side ranges and can serve at best
as only rough estimations of losses. All values
listed are in mEq. per 1,000 cc.2

Na

K

Cl

Gastric

59

9.3

89

Duodenum

104

5

99

Ileum

116

5

105

Ileostomy

129

16

109

Cecostomy

79

20

48

Urine

17-200

50

250

Bile

145

5

99

donald lamb is a resident in general surgery at
Veterans Administration Hospital, Minneapolis.

When estimating losses, it is important to be
sure of the location of the Miller-Abbott or
Levin tube. An easy way to do this is to test
the pH of the secretions. Those of the Miller-
Abbott tube, when in the small intestine, almost
always test alkaline. The secretions of the Levin
tube usually test acid but may test alkaline due
to reflux. Of course, a roentgenogram is best
when in doubt.

The necessity of using suction to prevent dis-
tention with shock, breakdown of gut anasto-
mosis, and wound dehiscence is well estab-
lished. Occasionally, tubes are left in too long.
They are usually left down until bowel sounds
have returned and peristalsis is capable of pro-
ducing flatulence and if the nasal gastric tube,
when clamped for two hours, does not produce
more than 30 to 50 cc of fluid.

ft is not surprising that some very interesting
electrolyte problems are encountered in surgery.
A few of the more common types will be dis-
cussed.

According to Moore, there are 3 types of low
sodium syndromes: sodium paradox, excess body
water with low or normal body sodium, and de-
creased body water with low or normal sodium
(dehydration). A slight decrease in serum so-
dium after operative trauma is due, in part, to
water shifting from the intracellular space at a
more rapid rate than the electrolytes. This pro-
duces a relative hyponatremia of the extracellu-
lar compartment and cellular dehydration. This,
according to Randall and associates,4 probably
explains the mechanism of decreased urine ex-
cretion on the basis of an increase in the anti-
diuretic hormone. Subsequently, a mild hypo-
natremia is produced, which promptly resolves
itself in the second to fifth postoperative day.
When the aforementioned condition is superim-
posed on a preoperative hyponatremia, usually
found in the general debilitated patient who also
frequently loses additional sodium from suction,
after traumatic surgery in patients with localized
edema, or in cases of traumatic peritonitis, a seri-
ous sodium deficiency results. This is often un-
recognized until shock or convulsions intervene.
To correct this deficit, the general condition of
a patient with low sodium should be built up

AUGUST 1958

347

preoperatively, but, in an emergency, adequate
replacement can be instituted.

The problem of hypochloremic alkalosis from
vomiting or gastric suction is usually one of
inadequate replacement and is encountered in
its severest form with pyloric obstruction. Treat-
ment consists primarily of replacement and sur-
gical correction. A rule of thumb commonly used
in restoring gastric and colon losses and small
bowel losses is to replace two-thirds of the gas-
tric and colon loss with normal saline and the
rest with dextrose and water, while liter for liter
of normal saline is used for small bowel losses
adding, in both instances, the estimated or meas-
ured potassium losses.

Flink5 believes that the problem of magnesium
deficiency may be expected during surgery in
patients with liver diseases and prolonged intra-
venous therapy. Muscle twitching, convulsions,
disorientation, and so forth may be remedied by
magnesium sulfate treatment.

The problem of “water intoxication,” excess
water with low or normal body sodium, is a
result of the excess administration of fluids,
which is, in a sense, antagonistic to the normal
surgical response of relative cellular dehydration
and the increased antidiuretic hormone, result-
ing in retention of water. It again is encountered
in the debilitated, traumatized patient.

When excessive blood loss is expected or a
patient is suspected of having decreased blood
volume prior to surgery, a blood volume deter-
mination preoperatively would be quite advanta-
geous in blood, fluid, and electrolyte manage-
ment, especially when compared to postopera-
tive blood volume studies. It is far more accu-
rate to measure the change than to resort to an
estimation of the change. The normal red cell
mass varies with sex and age. In general, old
people have a 10 per cent decrease in RCM. For
practical purposes, the RCM = hematocrit X
the blood volume. According to Perry and as-
sociates/’ normal values are obtained by divid-
ing the RCM in ec.’s by the ideal weight. The
ideal weight is based on life insurance weight
curves, adding one-third to one-quarter of a
pound for every pound of fat and subtracting
10 per cent if the patient is over 60 years old.
These values are 38.1 cc. per kilogram for normal
men, 34.3 cc. per kilogram for men over 50
years of age, 32.6 cc. per kilogram for normal
women, and 28.6 cc. per kilogram for women
over 50. Other than actual blood volume studies,
there are clinical signs which help in detecting
abnormal blood volumes. Tbe pulse increases
to maintain blood pressure with a decreased
blood volume, but shock develops when blood

volume is reduced to the point where increased
pulse and vasoconstriction are ineffective. A
warning of this end point can be elicited by hav-
ing the patient sit up and noting the change in
pulse and blood pressure, at which time he often
turns cold and clammy. An earlier index in cases
in which blood volume is chronically reduced is
the “dangle sign,” which occurs when the veins
in the dorsum of the hand fail to fill when the
hand is allowed to dangle.

In a twelve-hour distribution period, 1 unit
of blood will raise a decreased blood volume
.5 to 2 per cent and will increase a normal or
overloaded blood volume 3 to 6 per cent. Un-
fortunately, when overtransfusion exists, we usu-
ally cannot wait twelve hours to give another
unit of blood. Again, a pre- and postoperative
blood volume determination would be very in-
formative.

Fraser and associates7 feel that hypoproteine-
mia in the poor risk patient should be corrected
with 1,000 cc. of plasma a day and enough red
cells to correct the relative anemia and restore
blood volume preoperatively. This is usually
attained in three to six days.

WOUND CARE

The postoperative care of the surgical wounds
and preservation of a specific repair require
treatments that predispose to medical complica-
tions, particularly atelectasis, hypostatic pneu-
monia, and phlebothrombosis and their sequelae.
These antagonisms cannot be entirely prevented
but can be modified. The successful outcome of
a case often depends upon the proper applica-
tion of bandages. For example, when used for
support, the tight abdominal surgical dressing
should be applied in a manner that will allow
as complete diaphragmatic action as possible.
This can be accomplished by proper application
and frequent checking to make sure the dressing
does not slip up to cover the ribs. The scultetus
binder is notorious in this respect, and, as an
abdominal support, it is not infrequently applied
over the rib cage by inexperienced personnel.
In orthopedic and vascular homografts, it is fre-
quently imperative for the patient to remain
prone for extended periods. In such cases, mas-
sage, restricted passive motion, and properly
applied Ace bandages may prevent many com-
plications.

TACHYCARDIA

Tachycardia is usually a sign of an underlying
disturbance, but, if it is a bothersome arrhyth-
mia, the condition itself must be treated spe-
cifically. Embolization, atelectasis, pneumonitis,

348

THE JOURNAI.-LANCET

electrolyte imbalance, heart failure, fever, im-
pending shock, and myocardial infarction are
perhaps the most common causes of tachycardia
in the postoperative period, and treatment is
essentially directed at the underlying disturb-
ance.

METABOLIC CONDITIONS

The use of steroids in postoperative manage-
ment is paramount in Addison's disease, hypo-
pituitarism, bilateral adrenalectomy, unilateral
adrenalectomy when that adrenal has been hy-
perfunctioning, and in conditions in which the
adrenal glands have been suppressed by recent
steroid therapy.

The steroid requirements are greatly increased
for five to seven days after surgery or longer if
further stress develops. Galante and associates8
feel that steroids should be used if cortisone in
excess of 50 mg. per day for five days has been
used within two months prior to surgery or if
ACTII has been used within five days. Occa-
sional deaths from unrecognized adrenal insuf-
ficiency have been recorded months after steroid
therapy. These authors recommend a therapeu-
tic scale for postoperative adrenalectomy consist-
ing of progressively decreasing dosages of cor-
tisone over a seven-day period until a mainte-
nance level is reached with an addition of
DOCA on the fourth postoperative day. When
in doubt, steroids should be used. If the pre-
operative status is in doubt, a Thorn test may
be positive when adrenal function is adequate
for normal activitv but insufficient in times of
stress.9 Signs and symptoms of adrenal insuffi-
ciency are hypotension, fever, drowsiness, and
coma.

Gout, unlike rheumatoid arthritis and osteo-
arthritis, is made worse by surgery and is fre-
quently diagnosed in the postoperative period.
The arthritis usually manifests itself twenty-four
to thirty-six hours postoperatively. Uric acid
levels and roentgenograms fail to substantiate
the diagnosis in half of the cases. According to
Bartels,10 6 per cent of gout cases diagnosed
postoperatively are in women. He also states
that oral colchicine is usually contraindicated
in the postoperative period and suggests intra-
muscular ACTH, intravenous colchicine, or, if
single joints are involved, intra-articular hydro-
cortisone.

Warren11 does not believe that acute pan-
creatitis is a common complication of surgery in
the vicinity of the pancreas. This condition usu-
ally develops twenty-four to thirty-six hours after
surgery and is manifested by apprehension, pain,
abdominal distention, decreased or absent bowel

sounds, and epigastric tenderness. If an abscess
is present, pus or blood may accumulate in the
flanks, and extensive drainage may be required.

Cholangitis is usually the result of obstruc-
tion and not reflux as was formerly thought.

With adequate preoperative management, the
thyroid crisis is rarely encountered. Hypopara-
thyroidism, secondary to complete removal of
the gland, interference with the blood supply,
or removal ol a functioning adenoma is usually
recognized early and treated by the surgeon.

SURGERY FOR CORONARY ARTERY DISEASE

Etsten1- feels that only in an emergency should
surgery be performed on patients who have had
infarcts within three previous months. His inci-
dence of postoperative cardiac deaths in chronic
coronary artery disease is 0.8 per cent and, in
acute coronary artery disease, 18 per cent. It
is felt that the success of the operation is not
influenced by the type of anesthesia used. The
important factor is smooth induction, as strain-
ing, bucking, hypotension, and coughing reduce
coronary blood flow and increase the incidence
of infarction. Other factors predisposing to com-
plications are the depth of anesthesia, the main-
tenance of blood pressure, and adequate pulmo-
nary ventilation. Etsten feels that patients over
the age of 60 should be treated in the postopera-
tive period as if they had coronary artery dis-
ease. Baker13 believes that shock and prolonged
deep sedation tend to produce cerebral vascular
accidents.

POSTOPERATIVE HYPOTENSION

The problems of blood loss and adrenal insuffi-
ciency have been discussed. The following list
is incomplete but is an attempt to explain those
causes of hypotension peculiar to surgery and
anesthesia.

Acute gastric dilatation usually develops dur-
ing those “minor procedures” in which gastric
suction is rarely indicated. Four to eight hours
postoperatively, the patient, who is often sedated
and with no complaints, suddenly goes into
shock for no explainable reason. Percussion over
the stomach establishes the diagnosis, and gas-
tric suction corrects the condition.

Cyclopropane shock is rarely encountered with
the present standards of anesthesiology, and,
when it develops, it is quickly remedied and cor-
rected. The mechanism is due to a CCk. build-up
resulting from inadequate pulmonary ventila-
tion. Pure oxygen administered as the patient
is coming out of anesthesia drives off the re-
tained COj which, at high levels, stimulates the
respirations. For treatment, a mixture of CO->

AUGUST 1958

349

and 02 should he given. The medical counter-
part seen in chronic respiratory acidosis is noted
after postoperative administration of Ol>. In
these cases, intermittent ()2 or intermittent posi-
tive pressure breathing with compressed air is
indicated.

Pain in the recovery period is perhaps the
most common cause of postoperative hypoten-
sion and is readily alleviated with judicious use
of analgesics.

Anoxia, secondary to inadequate pulmonary
ventilation, must always be watched for as a
possible development. Some chest services do
routine six-hour postoperative bronchoscopies on
all patients. Local block tracheal suction, moist
air, judicious use of sedatives that suppress the
cough reflex, tracheotomy, postural drainage,
and early ambulation are essential in the treat-
ment of this condition. Also important is the pre-
operative indoctrination of the patient— teaching
him that he must cough and breath deeply when
asked to do so and urging cessation of smoking.

Peritonitis, either infectious or traumatic, can
produce large losses of plasma and produce de-

creased blood volume with no changes in red
cell mass. It is usually treated with plasma or,
if the patient is anemic, with both plasma and
blood.

Severe infection, especially streptococcal,
staphylococcal, coliform, and clostridial, may
produce shock which often requires blood, anti-
biotics, and surgical drainage. Antibiotics should
be given intravenously in these situations.14 The
mechanism of the shock is caused by loss of fluid
into inflamed tissue or space and by toxemia
with its direct action on the heart and adrenal
glands and a direct effect on the erythrocytes,
decreasing their ability to transport oxygen.

Perhaps one of the most dramatic causes of
postoperative shock is acute enterocolitis. The
incidence seems to be highest following gastric
surgery, operations on patients with acute en-
teritis, and after administration of broad spec-
trum antibiotics. The signs and symptoms are
violent diarrhea, vomiting, shock, dehydration,
anemia, and death. The mortality rate is very
high. In a recent report,15 6 of 8 patients died
within two days after the condition developed.

REFERENCES

1. Moore, F., and Ball, M. R.: The Metabolic Response to

Surgery, ed. 1. Springfield, Illinois: Charles C Thomas, 19.52.

2. Randall, H. T.: Water and electrolyte balance in surgery.

Surg. Clin. North America 32:445, 1952.

3. Scallen, R.: Low sodium syndrome. Med. Crand Rounds,

VA Hospital, Minneapolis, 1954.

4. DeCosse, J. J., Randall, H. T., Habif, D. V., and Roberts,

K. E.: Mechanism of hyponatremia and hypotonicity after

surgical trauma. Surgery 40:27, 1956.

5. Flink, E. B.: Magnesium deficiency syndromes in man.

J.A.M.A. 160:1406, 1956.

6. Perry, F. A., Randall, H. T., Poppell, J. W., and Rob-
erts, K. E.: Blood volume replacement in surgery. Surg.

Clin. North America p. 30, April 1956.

7. Fraser, C. G., Preuss, F. S., and Bigford, W. D.: Adrenal
atrophy and irreversible shock associated with cortisone ther-
apy. J.A.M.A. 149:1542, 1952.

8. Galante, M., Rukes, J. M., Forsham, P. H., and Bell, H.
G.: Use of corticotropin, cortisone, and hydrocortisone in gen-
eral surgery. Surg. Clin. North America 34:1201, 1954.

9. Hurxthal, L. M.: Postoperative shock due to adrenal in-

sufficiency. Surg. Clin. North America p. 715, June 1957.

10. Bartels, E. C.: Gout as a complication of surgery. Surg.

Clin. North America p. 845, June 1957.

11. Warren, K. W.: Complications of pancreatic surgery. Surg.

Clin. North America p. 683, June 1957.

12. Etsten, B., and Proger, S.: Operative risk in patients with
coronary heart disease. J.A.M.A. 159:845, 1955.

13. Baker, A. B.: Clinical Neurology, ed. 1. New York: Paul B.
Hoeber, Inc., 1952.

14. Symposium on shock. Army Med. Service Grad. School.

15. Hultborn, K. A.: Acute postoperative enterocolitis. Acta

chir. scandinav. 111:29, 1956.

Ale solitary or multiple adenomatous nodular goiters in men, children, and
adolescents should be removed because of the high incidence oi associated
thyroid cancer. In adult women, removal of solitary adenomas is advisable,
hut resection of multiple adenomatous goiters is not always justified, since the
incidence of malignant transformation is low.

Of 879 adenomatous goiters, 3.4 per cent proved to be malignant. In men,
10.5 per cent of multiple adenomas and 14 per cent of solitary adenomas were
malignant, as compared with 1.2 and 3.4 per cent, respectively, in women.
In patients between 1 1 and 20 years of age, the incidence of carcinoma was
9.9 per cent.

Charles D. Hershey, M.D., Wheeling Clinic, Wheeling, West Virginia. Arch. Surg. 76:407, 1958.

350

THE JOURNAL-LANCET

Debridement and Panarthrodesis for Spinal
Tuberculosis and Simulative Disease

A Preliminary Report

R. H. HALL, M.D., and B. M. ADAMSON, M.D.

Long Beach, California

Posterior fusion has been a time-honored
form of surgical treatment1 2 to hold stable
those vertebrae involved in Pott’s disease of the
spine. In the pre-streptomycin days, the sur-
geon who contemplated debriding or even di-
rectly opening a Pott’s abscess could usually
anticipate secondary infection, possible spread
of the tuberculous disease, and chronic drain-
age.3-3 Although Treves5 first recorded direct
surgical debridement for spinal caries in 1884,
it was not until the advent of streptomycin in
1947 that this direct surgery became more prac-
ticable. Bv 1952, the effects of streptomycin on
bone and joint tuberculosis had been investi-
gated and reported by Bosworth and Wright15
and many others. In the United States, Johnson
and associates7 reported that direct attack of
tuberculous spondylitis was safe, and they used
this method to aid in differential diagnosis.
Meanwhile, Wilkinson,8 in England, re-empha-
sized that a Pott’s abscess produced endarterial
occlusion at the periphery of the surrounding
wall, thus blocking parenteral streptomycin from
crossing the interface and entering the cavity.
To encourage the antibiotic in reaching the dis-
eased tissue, he did debridement alone of the
abscess and wall. Kastert,11 in Germany, emptied
the abscess, leaving the wall intact as a barrier
against spread of the disease and treated the
patient postoperatively bv local antibiotic in-
stillations through a catheter into the diseased
area. Fellander,10 in Norway, Kirita,11 in Japan,
and Sanchis-Olmos,12 in Spain, all have reported
small series of patients in whom they debrided

r. h. hall and b. m. adamson at the time of writ-
ing ivere with the Orthopedic Surgical Section of
the United States Veterans Administration Hospital
at Long Beach, California, and the University of
Southern California School of Medicine at Los An-
geles.

Paper presented at the American Academy of
j Orthopedic Surgery meeting in Chicago, January
31, 1957.

the abscess and placed bone in the cavity to
form a solid fusion. Some of their reported re-
sults have been very encouraging.

In January 1953, we began to debride Pott’s
abscesses and fuse both anteriorly and posterior-
ly, primarily because the complications, seque-
lae, and recurrent disease from previous methods
of management seemed excessive. Our attention
had been drawn to the ease of entering the ver-
tebral body while employing the retroperitoneal
approach used by Weinberg1314 for psoas ab-
scess excision, a route in which the approach to
the lumbar spine so much resembles that used
for nephrectomy.

In our plan of treatment and follow-up care,
we have established several well-defined goals.
We plan to excise the cavity walls, sequestra,
and other debris; try to obtain solid bony fusion
between the vertebral bodies and posterior ele-
ments across the diseased vertebrae as judged
by two anterior posterior and two lateral roent-
genograms taken with the patient bending; give
adequate chemotherapy for at least one year
postoperatively; and await clinical quiescence
of the disease and normal laboratory findings.
We have tried to make certainty, rather than
rapidity, of arrest of the disease our objective.
Preliminary bed rest in a plaster jacket and the
administration of a combination of streptomycin,
para-aminosalicylic acid, and isoniazid are given.
Daily streptomycin in a 1 gm. dose is first given
for one month, usually prior to and following
surgery. The dosage is then reduced to semi-
weeklv injections of 1 gm. for a year or more.
During this interim phase, other foci of tuber-
culosis are treated by recognized means, includ-
ing resectional surgery where indicated. When
clinical and laboratory signs indicate that the
patient has gained sufficient resistance to his dis-
ease and the tuberculous process has quieted
sufficiently, the vertebral focus is attacked.

In lumbar disease, the incision lies in the flank
paralleling the anterior primary divisions of the

AUGUST 1958

351

lower thoracic spinal nerves and is the same as
the “sympathectomy” approach.14 Although we
have approached the spine from each side, the
left side is preferred, wherever there is a choice,
because the aorta is less vulnerable than the
vena cava. The sympathetic chains lie antero-
laterally to the vertebral bodies and, if either
one gets in the way, it can be displaced without
interruption. In the presence of a large psoas
abscess where there is a possibility that anatomic
landmarks will be obscured, it is well to insert
a ureteral catheter preoperatively. If a psoas
abscess is present, it is excised first.1314 Using
portable roentgenograms and metal markers if
necessary, the abscess in the vertebrae is located
and opened. Part of the psoas or diaphragmatic
slips of origin may be divided or retracted to
expose the diseased vertebral area. The antero-
lateral vertebral and annular ligaments are in-
cised and reflected sufficiently for good expos-
ure. The debris and sequestra are lifted free,
after which the degenerated disk and scar tissue
are removed. Next, the sclerotic bony walls are
excised, exposing cancellous bone of the adja-
cent vertebrae (figure la). Milled granules of
cancellous bank bone are then packed into the
cavity. These serve effectively to control bleed-
ing from the raw bone surfaces (figure 1 b). Ap-
proximating the separated ligamentous or mus-
cle fibers closes the cavity, retaining the bone
chips. A drain is used only if a psoas abscess
has been removed.

In 2 patients (cases 9 and 10), thoracic inter-
vertebral disk spaces were involved. In case 9,
the diseased area was approached retroperito-
neallv by resecting the twelfth rib. This ap-
proach proved rather difficult and awkward,
especially for curetting the eleventh thoracic
disk space. The eleventh thoracic interspace in
case 10 was approached through a transpleu-
ral incision with resection of the eighth rib.
This proved to be a much easier approach, and
it was noted that the twelfth thoracic interspace
could have been entered readily. The twelfth pa-
tient had disease of his fourth and fifth cervical
vertebrae. Approaching the disk space from the
side just behind the sternocleidomastoid muscle
and in front of the vertebral artery presented no
unusual difficulties. The common carotid artery
and its accompanying vessels and nerves were
retracted forward together with the other adja-
cent soft structures. Spreading apart a few fibers
of the long neck muscles revealed the diseased
area.

The patients were nursed postoperatively in
a preformed, bivalved body cast, which had bi-
lateral thigh extensions for lumbar areas, and for

Fig. la. Diseased debris and sclerotic walls have been
removed, (b). Milled granules are injected and packed
into cavity remaining.

low thoracic areas included the shoulders. For
our one cervical case, a snug Minerva jacket was
used. About two months after the primary in-
terbody debridement and grafting, a Hibbs’ type
posterior laminar and facet fusion of onlv the
diseased vertebrae was done. Three months after
the last operation and at quarterly intervals
thereafter, the aforementioned 2 plane roent-
genograms were made to help determine solidity
of the fused area. When the panarthrodesis was
deemed solid, the patient became ambulatory.
A brace sometimes was employed, primarily to
remind the patient to guard his back until the
roentgenograms showed complete consolidation.
In our one cervical case, the posterior approach
followed the anterior under the same anesthetic.
A preliminary tracheotomy was performed as a
precautionary measure.

We have used this plan of therapy on 12 pa-
tients with suspected tuberculous spines. Two
of the patients according to cultures and tissue
examination were found to have nontuberculous
disease. Three others could not be confirmed or
disproved by cultures and tissue examination.
T he levels of disease in these patients ranged
from the fifth cervical through the fifth lumbar
interspaces. Three patients had two interspaces
involved.

One- to four-year follow-up examinations have
been made in all cases. They appear to be solidly
fused as judged by 2 plane roentgenograms.
However, the anterior grafts do not all show
completed bony incorporation, as it sometimes
takes two or more years for retrabeculation to
appear. By our standards, these patients have
arrested spine disease.

The complications so far have been largely
technical. Abdominal wall weakness and bulging

352

THE JOURNAL-LANCET

from the interruption of motor nerves developed
postoperatively in 2 patients. In another patient
(case 7), the posterior end of his incision started
to drain four months after operation. Drainage
persisted for five months and ceased spontane-
ously. Hemolytic Staphylococcus aureus organ-
isms were grown on cultures from this drainage
as well as from the tissue removed at the surgical
debridement.

CASE REPORTS

Case 1. Our first patient was a 30-year-old Caucasian
veteran whose back pain began in 1942. He was found
to have tuberculous spondylitis of the second, third, and
fourth lumbar vertebral bodies. Subsequently, three at-
tempts at fusion of his lumbar posterior elements failed.
In January 1953, an operation consisting of a debride-
ment and anterior interbody fusion was done from the
second to the fourth lumbar vertebrae. Three months
later, the areas of nonunion in the posterior elements
seemed bridged solidly by bone. Nine months later, the
spine appeared solid in routine 2 plane roentgenograms.
The patient now works eight hours daily as a small
motor electrician.

Case 2. The second patient was a 32-year-old white
minister who first felt back pain in January 1953. Six
months later, tuberculous spondylitis of his fifth lumbar
and first sacral vertebrae was diagnosed and he was
started on our plan of therapy. In July 1953, the fifth
lumbar vertebral interspace was curetted and packed
with bone chips. In May 1954, a posterior element fusion
across this interspace was performed. Seven months
later, the spine appeared solid in 2 plane roentgeno-
grams. The patient now works as a full-time salesman.

Case 3. The third patient was a 65-year-old white
retired laborer who had pulmonary tuberculosis in 1919
which again became active in 1952. Active disease was
also found in bis fifth lumbar and first sacral vertebrae.
This diseased area was curetted and grafted anteriorly
in October 1953. Four months later, the spine appeared
solid in 2 plane roentgenograms. He is the only patient
in this series who has not had posterior surgical fusion
on his spine. However, upon reviewing his postoperative
roentgenograms, a solid bony bridge appears to have
developed spontaneously between the spinous processes
and laminae at the lumbosacral level. The patient is still
retired.

Case 4. The fourth patient was a 33-year-old Cau-
casian cabinet maker who had five years of low-back
pain before a working diagnosis of tuberculosis was
made in May 1953. During a planned therapeutic pro-
gram in March 1954, debridement and bone grafting
was done at the third lumbar interspace. Tissue sec-
tions examined microscopically confirmed the diagnosis
of tuberculosis. Three months postoperatively, the spine
was judged solid by 2 plane roentgenograms. In Sep-
tember 1954, the same interspace was grafted posterior-
ly. He is now working and is asymptomatic.

Case 5. The fifth patient was a 34-year-old colored
cook who had had pulmonary tuberculosis diagnosed in
1949. Backache started in March 1952. Eight months
later, bis first and second lumbar vertebrae were found
diseased. Destruction progressed, and kyphosis appeared.
In August 1954, debridement of the abscess and inter-
body fusion was done. Tissue sections confirmed the
diagnosis of tuberculosis. A posterior element arthrodesis
was performed in September 1954. One year later, com-

plete stability was demonstrated. The patient now works
full-time in the post office, lifting packages and doing
rather heavy work.

Case 6. The sixth patient was a 28-year-old white
serviceman who first recalled low-back pain early in

1954. By December, a diagnosis of fourth and fifth lum-
bar vertebral disease was made and therapy started. In
March 1955, anterior curettage and fusion was done,
which was followed by posterior arthrodesis in June

1955. The diagnosis of tuberculosis was confirmed by
the Pathology Department. Stability was judged com-
plete two months later. He is now ambulating without
a brace and is working, but he is not back in the service.

Case 7. The seventh man, a 59-year-old white ranch-
er, hurt his back in a fall in 1953. Pain which originated
from the trauma continued, and roentgenograms dem-
onstrated a destructive lesion of his third lumbar body
superiorly. The patient had been told as early as 1924
that he had tuberculosis. In 1927, he had left knee pain
and swelling, which were later diagnosed from roent-
genographic appearances as tuberculous. With continu-
ous casts for five years, the knee joint ankylosed spon-
taneously. In November 1953, the second lumbar inter-
space was debrided, and a fusion was performed. Hemo-
lytic Staphylococcus aureus was grown from cultures,
and tissue sections showed a few areas of chronic in-
flammatory tissue without pathologic evidence of tuber-
culosis. Four months after primary healing, a draining
sinus developed and continued for five months before
closing spontaneously. In September 1954, a posterior
arthrodesis was done. Seven months later, both fusions
were solid, and the patient was as active in ranch work
as he had been before surgery.

Case 8. The eighth patient was a 62-year-old white
retired warehouseman who, after many years of back
pain, had had a posterior fusion from his eleventh tho-
racic to his second lumbar vertebrae performed in No-
vember 1953. Despite apparent solidity of the fused
area, his pain continued. In July 1954, the twelfth tho-
racic and first lumbar interspaces were curetted. Bone
graft material was packed into the region of the first
lumbar interspace only, because the twelfth space did
not appear diseased upon inspection. In the tissue sec-
tions, no typical areas of tuberculosis could be found.
Nine months later, the twelfth thoracic and first lumbar
interspaces both appeared to be filled with bone. The
patient did not work before, nor does he now, but says
he feels well insofar as his back is concerned. He com-
plains of a bulge in his abdominal wall at the incisional
scar level.

Case 9. The ninth patient was a 34-year-old white
television repairman who said he had had severe recur-
rent nr'dbaek pains for twenty years. A diagnosis of tu-
berculous spondylitis of his tenth, eleventh, and twelfth
thoracic vertebrae was made in 1945 from serial roent-
genogram changes. Posterior fusion from the tenth tho-
racic to the first lumbar arches was carried out. Because
of persistent pain which gradually increased in severity
in spite of a solid posterior element bridge, the twelfth
thoracic and first lumbar interspaces were debrided and
fused anteriorly in February 1955. The tissue removed
at operation did not appear tuberculous macroscopically,
and cultures failed to grow acid-fast organisms. Chronic
nontuberculous inflammatory reaction was observed mi-
croscopically in the excised tissue sections. The patient
returned to work in July 1955, and his back is comfort-
able. There is asvmptomatic bulging in the left flank at
the incis'onal line.

Case 10. The tenth patient was a 34-year-old con-
struction worker who had had an insidious onset of mid-

AUGUST 1958

353

back pain in October 1955. A destructive lesion of his
eleventh and twelfth dorsal vertebrae with paraspinal
soft tissue swelling was seen in a roentgenogram in De-
cember 1955. In March 1956, anterior debridement and
fusion of the diseased area was accomplished, and, in
May, a posterior element arthrodesis was done. Preop-
erative aspiration material and surgically excised tissue
grew Staphylococcus aureus on cultures. Microscopic
sections showed chronic nonspecific inflammatory tissue
with sequestration. His postoperative course was that
of progressive uncomplicated healing.

Case 11. The eleventh patient was a 27 -year-old col-
ored automobile body assembler who began to have low-
back pain in April 1955. This pain subsided onlv to
recur in October and to be complicated by a swelling
in his right upper anterior thigh in February 1956. A
clinical diagnosis of tuberculosis of his fourth lumbar
interspace and the left sacroiliac joint was established.
Diseased areas were excised, including a right psoas ab-
scess sac, the fourth lumbar disk and adjacent body sur-
faces, and the left sacroiliac joint and adjacent bony
surfaces. Surgery was carried out in two stages. The
first, in April 1956, consisted of psoas abscess excision,
debridement, and interbody arthrodesis. The second
stage, done in June, consisted of posterior element fusion
of the fourth and fifth lumbar arches and, in addition,
the debridement plus bone grafts to the left sacroiliac
joint. His areas of fusion are solid, and he is clinically
asymptomatic.

Case 12. The twelfth patient was a 34-year-old man
who had had an ankylosed spine from Marie-Striimpell
arthritis for nearly ten years. Without any definite etio-
logic traumatic episode, some brachial plexus paresthe-
sia and some atrophy of the small muscles in his hands
had developed very, very slowly over about two years,
and a progressing dislocation of the fourth cervical ver-
tebra forward on the fifth was apparent in the lateral
roentgenograms. Although motion was still possible at
the first cervical level, the rest of the cervical spine had
been fused solidly by his disease process, and the dis-
location had developed secondary to some sort of pa-
thology in the fused area. After discontinuing steroid
therapy, fixation was accomplished by use of a Minerva
jacket. After three months of immobilization, no im-
provement could be determined objectively, and bend-
ing films demonstrated that motion was still present at
the level of disease. Accordingly, antituberculous therapy
was instituted. In August 1956, a preliminary trache-
otomy was followed by an anterior debridement and
bone graft, which, in turn, was followed by a posterior
Hibbs’ type fusion with interspinous process wire fixa-
tion. Postoperatively, healing occurred without compli-
cations. The sections for microscopic study and cultures
taken from tissue removed at surgery have yielded no
specific information other than chronic inflammatory dis-
ease with necrosis and degeneration. The paresthesia has
regressed, and his area of fusion is solid.

DISCUSSION

It has been interesting to note that whenever,
as in the first patient, a posterior element fusion
failed or was delayed, addition of the anterior
interbody fusion was followed by rather rapid
arthrodesis of both sites. The reverse was also
seen, as in the second patient, when ten months
after primary debridement and bone grafting,
the interbody space showed no tendency to con-
solidate. A posterior element fusion then was

followed by fairly rapid consolidation of both
sites.

It is also noteworthy that cases 8 and 9 had
continuous or recurrent symptoms in spite of a
solid posterior element fusion. Both of these pa-
tients were completely relieved of their back
symptoms after the anterior debridement and
panarthrodesis. Cases 7, 8, 9, 10, and 12 again
emphasize the fact that spinal caries is not nec-
essarily always tuberculous in origin.

Although we are confident that a certain per-
centage of these patients would have been all
right with a single fusion either anteriorly or
posteriorly, nevertheless, we feel the combined
surgery is well justified. In the first place, we
have never had any increase of vertebral destruc-
tion or kyphosis subsequent to surgery. Second,
the abscess found at surgery at times has been
much larger than was apparent in preoperative
roentgenograms. And, finally, we have observed
progression of disease activity objectively as well
as subjectively in the presence of a solid pos-
terior element fusion — a progression which has
ceased only when natural processes have created
a solid interbody arthrodesis anteriorly. Thus,
we feel we are actually hastening arrest of the
disease in many individuals and, at the same
time, are assuring arrest in all patients, which is
not possible by other methods.

In following the progress of these diseased
spines, we have found serial measurements of
serum enzvme inhibitor levels15 to be helpful.
The chymotrypsin inhibitor level, elevated in the
presence of disease activity, returns to normal
when the disease process becomes isolated or
controlled by the body processes or when the
disease process has been excised surgically. Used
in conjunction with the rennin inhibitor level,
a pattern is obtained which we have utilized in
over-all evaluation of the patients’ condition
prior to and following surgery. A few times we
have found a disturbed pattern to be the only
objective evidence of disease.

One of the most gratifying aspects of this
treatment is the pronounced postoperative re-
lief which some patients obtain after debride-
ment. Occasionally, their preoperative symp-
toms have been so severe that their personalities
have become altered to a degree that psycho-
neurosis, malingering, or narcotic addiction has
been suspected. Once the diseased tissue has
been removed, the personality has frequently
improved almost overnight. A few have said they
felt better during even the first twentv-four hours
postoperatively than in previous months.

The surgery herein described has been under-
taken and made possible through the close co-

354

THE JOURNAL-LANCET

operation, advice, and assistance from the other
surgical specialties. We are not recommending
that our surgical program he universally or even
generally adopted. We wish to emphasize the
great degree of caution necessary when working
in close proximity to the great vessels.

SUMMARY

We have presented a preliminary report on the
details of our management of destructive, granu-

lomatous, infectious (presumably tuberculous)
disease of the spine. The essential surgical con-
tribution is the direct debridement and pan-
arthrodesis of the diseased vertebrae. In our
hands thus far, this program has been extremely
gratifying with no disease recurrences or re-
activations and few complications. This is a
preliminary one- to four-year study which we
anticipate will be augmented later by more cases
followed for longer periods.

REFERENCES

1. Albee, F. H.: Report of bone transplantation and osteo-

plasty in treatment of Pott’s disease of spine. New York M.
J. 95:469, 1912.

2. Hibbs, R. A.: An operation for Pott’s disease of the spine.

J.A.M.A. 59:433, 1912.

3. Hiromu, I., Tsuchiya, J., and Asami, G.: New radical op-

eration for Pott’s disease. J. Bone & Joint Surg. 32:499. 1934.

4. Muller, W.: Transperitoneale Freilegung der Wirbelsaule

bei tuberkuloser Spondylitis. Deutsche Ztschr. during. 85:
128, 1906.

5. Treves, F.: Direct treatment of psoas abscess with caries of
the spine. Tr. Med. Chir. 67:113, 1884.

6. Bosworth, D. M., and Wright, H. A.: Streptomycin in

treatment of bone and joint tuberculosis. J. Bone & Joint
Surg. 34-A:255, 1952.

7. Johnson, R. W., Jr., Hillman, J. W., and Southwick, W.

().: Importance of direct surgical attack upon lesions of the

vertebral bodies, particularly in Pott’s disease. I. Bone & Joint
Surg. 35- A: 17, 1953.

8. Wilkinson, M. C.: Treatment of tuberculosis of the spine

by evacuation of the paravertebral abscess and curettage of

the vertebral bodies. J. Bone & Joint Surg. 37B:382, 1955.

9. Kastert, J.: Die operative Herdausraumung bei Spondylitis

Tuberkulosen. Ztschr. Orthop. 84 ( supp. ) : 17, 1954.

10. Fellander, M.: Radical operation in tuberculosis of the

spine. Acta orthop. scandinav. Supp. 19, 1955.

11. Kirita, Y., and Nakajima, H.: Debridement of tuberculous

focus and treatment of dead cavity in iliosacral joint tubercu-
losis (English abstract). Arch. jap. Chir. 22:148, 1953.

12. Sanchis Olmos, V.: El abordaje directo de los cuerpos ver-

tebrales en el mal de Pott. Acta ortop-traumatol. iber. 1 :
471, 1953.

13. Weinberg, J. A.: Surgical extirpation of tuberculous psoas

abscess, preliminary report on 6 cases. West. J. Surg. 59:
584, 1951.

14. Weinberg, J. A.: Surgical excision of psoas abscesses result-

ing from spinal tuberculosis. J. Bone & Joint Surg. 39A:17,
1957.

15. Hall, R. H., and Eli. is, F. W.: Serum proteolytic enz'me

inhibitors in bone diseases. J. Bone & Joint Surg. 38A:1254,
1956.

In infants and children, symptoms of periostitis may simulate paralysis of
congenital syphilis or poliomyelitis, but roentgenograms show periosteal re-
action. Since periostitis subsides without treatment and rarelv leaves residual
manifestations even in the roentgenogram, differentiation from more serious
skeletal lesions is essential.

Antecedent trauma has often been forgotten, since even slight injury may
cause extensive subperiosteal hemorrhage and stripping of the periosteum.
The child is reluctant to move the limb and may complain of pain, and the
affected area may be swollen and extremely tender.

Roentgenograms made immediatelv after injury are negative. About a week
later, calcification and formation of new subperiosteal bone is evident. The
new bone involves only the shaft, never extending beyond the epiphyseal line.
The subperiosteal cloaking may appear as a faint line along the shaft or may
resemble the massive, calcified subperiosteal hematoma of scurvy. A faint
fracture line of epiphyseal displacement is sometimes seen.

Differential diagnosis includes congenital syphilis, poliomyelitis, congenital
cortical hyperostosis, osteomyelitis, scurvy, and bone tumor.

Morris S. Friedman, M.D., Northern Indiana Children’s Hospital, South Bend. J.A.M.A. 166:
1840, 19.58.

AUGUST 1958

355

Power Lawn Mowers — A New Hazard

JOHN N. McCLURE, Jr., M.D., F.A.C.S.
Atlanta, Georgia

Injuries produced by rotary-type power lawn
mowers may cause loss of life, limb, and eye-
sight and other permanent disabilities. Such in-
juries also may be responsible for considerable
economic loss to the families involved. There is
great need for accident prevention programs and
safety education with regard to use of these
machines. According to the United States De-
partment of Commerce, 362,249 power lawn
mowers were manufactured in the United States
in 1947. Last year, approximately 3M million of
them were sold, and the Lawn Mower Institute,
trade organization of lawn mower manufac-
turers, estimates that there are now over 12
million in use.

With the increase in the number of power
lawn mowers manufactured and used has come
an apparent increase in the number of injuries
caused bv them.

The most popular type of mower is the gaso-
line rotary, which is responsible for about all
of the serious injuries.

In addition to cutting anything which comes
into its path, the revolving blades may pick up
and throw with bullet-like force bits of wire,
nails, glass, bolts, bones, and so forth. These
may strike not only the operator of the machine
but someone nearby or across the street. Lethal
wounds involving brain, heart, and neck have
been reported as well as fatalities from tetanus
—secondary to such injuries. Some of the more
common type wounds are shown in the accom-
panying illustrations.

A survey of approximately one-half of the
physicians in private practice in Georgia, con-
ducted bv the Accident Prevention Unit of the
Georgia Department of Public Health, revealed
794 injuries during the years 1955 and 1956.
Among the injuries reported, rotary mowers
were definitely responsible for 88 per cent, and
the reel mowers caused 7.7 per cent. Among all
injuries, 70 per cent were caused by direct con-
tact with the mower, and 30 per cent were
caused by objects thrown by the mower.

john n. mcclure, jr. is a surgeon at the Buckhead
Clinic, Atlanta.

The anatomic regions involved are shown in
table 1. Note the relatively high percentage of
eye injuries among the missile-type wounds.
The study also revealed that complications de-
veloped in 9.4 per cent of the wounds, such as
infections, thrombophlebitis, pulmonary emboli,
and so forth, and that permanent disability of
some kind followed in 14 per cent of the cases.

SUMMARY AND CONCLUSIONS

The fact that power lawn mower injuries can
cause loss of life, limb, and eyesight and other
permanent disabilities has been stressed. Tbe
number of such injuries has apparently increased
with the widespread use of these machines.
There is great need for safety education with
regard to the proper operation of the power
lawn mower. Also needed is a safety standard
to be followed by manufacturers. It would
seem reasonable that manufacturers be allowed
to sell only machines meeting certain minimum
safety standards. The power lawn mower has
thus created a great need for an extensive acci-
dent prevention program involving manufactur-
ers and sellers as well as users of these machines.
Physicians, medical societies, public health de-
partments, safety organizations, and local and
national insurance companies should be respon-
sible for the development of this kind of a pro-
gram. The institution of such a campaign offers
a challenging opportunity for those interested
in accident prevention.

Fig. 1. Wound of right globe by rock thrown by rotan
power mower. Enucleation necessary. Courtesy Dr. Mor-
gan Raiford.

O

356

THE JOURNAL-LANCET

TABLE 1

REGIONS OF BODY INVOLVED

Number

Per cent

Injured by direct contact with

mower :

Toes or feet

366

66

Fingers or hand

143

26

Other areas

44

8

Total

553

100

Injured by objects thrown by

mower :

Lower extremities

167

69

Trunk

6

3

Upper extremities
Head and neck

12

5

( excluding eyes )

17

7

Eyes

39

16

Total

241

100

Fig. 3. Amputation of 2nd, 3rd, and 4th toes and tip
of great toe by rotary mower.

Fig. 2. Division of Achilles tendon, posterior tibial vessel
and nerves, and laceration of tibia by rotary mower.

Fig. 4. Loss of end of middle finger and laceration of
tip of ring finger by direct contact witli rotary mower.

Fig. 5. Short piece of wire thrown by rotary mower
deep into leg. Courtesy of Dr. Jack Schreeder.

Fig. 6. Heavy wire driven in and out the foot by rotary
mower.

AUGUST 1958

357

The Prevalence and Incidence of Multiple
Sclerosis in Missoula County, Montana

HOWARD D. SIEDLER, M.D., WILLARD NICHOLL, M.D.,
and LEONARD T. KURLAND, M.D.

Bethesda, Maryland, and Missoula, Montana

SOME OF THE STAFF NEUROLOGISTS at tile Mayo

Clinic have had the impression that a rela-
tively larger number of patients with multiple
sclerosis are being referred to the clinic from
the Montana-Idaho area than from other parts
of the country. This impression was conveyed
to us, and a study of the prevalence and inci-
dence of multiple sclerosis in Missoula, Mon-
tana, was undertaken. Missoula was chosen for
this statistical survey because of its central loca-
tion in this northwesern area, its convenient size,
and the high level of local medical practice. Two
similar studies in small northern cities were
referred to for comparison.12

If it had been found that multiple sclerosis
is significantly more prevalent in Missoula than
in other northern cities previously studied, an in-
tensive epidemiologic investigation was planned
in an attempt to discover important local factors
which might account for this difference.

METHODS

The locality. Missoula, Montana, is situated in
the far west-central part of the state and is 205
miles east of Spokane, Washington. The altitude
of the citv is 3,223 ft. In planning this study,
it was decided to restrict the population inves-
tigated to those living within Missoula County.
Missoula County represents an area of 2,640
square miles, and the estimated population in
1956 was 42,600. Approximately 70 per cent of
the population lives in the city of Missoula, and
all of the physicians practicing in Missoula
County have their offices in the city of Missoula.

Case finding. A number of sources of medical
information were surveyed in attempting to lo-

howard d. siedler is an epidemic intelligence serv-
ice officer assigned to the Epidemiology Branch of
the National Institute of Neurological Diseases and
Blindness, Bethesda , Maryland, willahd nicholl
is an internist at The Western Montana Clinic, Mis-
soula. Leonard t. kurland is chief of the Epi-
demiology Branch of the National Institute of Neuro-
logical Diseases and Blindness, Bethesda.

cate all patients who had been diagnosed or
were suspected of having multiple sclerosis.
All of the Missoula physicians and several from
surrounding counties were contacted personally,
and information on patients living in the county
was requested. Several neurologists from other
areas to whom Missoula County patients were
often referred were asked for similar informa-
tion. A list of patients was obtained from the
Missoula chapter of the National Multiple Scle-
rosis Society. Case records from a local Veterans
Administration Hospital were reviewed. A phy-
sician in Helena, Montana, who has multiple
sclerosis himself, offered additional material.

Diagnostic categories. Following neurologic
examination in most instances and a review of
detailed clinical reports in a few, patients were
classified as (1) probable, (2) possible, and (3)
not cases of multiple sclerosis. The criteria for
this classification follows:

( 1 ) . Probable multiple sclerosis pertained to
patients with neurologic signs and symptoms
characterized by exacerbations and remissions or
by slow progression of lesions. In all cases,
objective documented neurologic findings were
explainable only by the assumption of multiple
lesions in the central nervous system. Historic
evidence, laboratory findings, and examination
results supported the impression of multiple scle-
rosis and were against other diagnoses.

(2) . Possible multiple sclerosis included pa-
tients who, in most cases, had insufficient evi-
dence of multiple lesions in the central nervous
system on the basis of neurologic examination.

(3) . Not multiple sclerosis represented those
for whom another diagnosis was more likelv.

Only probable cases were counted in com-
puting the incidence and prevalence rates.

Determining rates. When the number of pa-
tients living in the county on the arbitrarily
chosen date of January 1, 1957, was determined,
the prevalence rate was calculated on the basis
of the estimated population figures for the coun-
tv on that date. If a patient had moved to Mis-

358

THE JOURNAL-LANCET

soula County before January 1, 1957, to facilitate
medical or nursing care, this case was excluded.
Likewise, if a patient left Missoula County prior
to that date for treatment or nursing care else-
where, this case was included. There was 1 case
in the first and 2 cases in the latter category.

The average annual incidence was calculated
on the basis of the average yearly number of pa-
tients who had the onset of their disease while
living in the county between 1940 and 1950. The
average of the population figures for these two
years was used in determining the rate. Prob-
lems of mortality reporting and the small size
of the population group studied made the deter-
mination of a mortality rate impractical. How-
ever, an average annual mortality rate for Mon-
tana for the years 1950 through 1954 was calcu-
lated for comparison with the average United
States rate for this period.

RESULTS

Information was obtained on 38 patients sus-
pected of having multiple sclerosis who were
living in or had lived in Missoula County. Of
these, 29 were interviewed and examined. Suf-
ficient preliminary information was available
from 3 of the remaining 9 patients to determine
that they were ineligible. Three patients were
not examined at the time of the study hut were
included in the frequency figures on the basis
of records submitted by other physicians and

TABLE 1

CLASSIFICATION OF 38 MULTIPLE SCLEROSIS SUSPECTS

Patients Patients tint
examined examined Total

Probable M S
eligible for study

Probable M S

ineligible for study

Possible M S
Not M S

Insufficient information
Total

22 3 25

1 3 4

3 1 4

3 - 3

_ 2 2

29 9 38

information obtained from the patients. Table 1
shows the final result of the classification.

Prevalence rate. Of the 29 patients examined,
23 were classified as probable cases, and, of
these, 22 were eligible for the prevalence figure.
With the addition of the 3 patients mentioned
previously, who were classified as probable cases
though not examined by us, the total of 25 prob-
able cases fulfilling the criteria for the preva-
lence data gives a rate of 59 per 100,000 based
on the estimated county population of 42,600
on January 1, 1957. This rate compares closelv to
rates obtained in the Rochester, Minnesota, and
the Kingston, Ontario, studies (table 2).

Incidence rate. Six patients with probable
mutliple sclerosis were found in whom onset of
their disease occurred between 1940 and 1950
while living in Missoula County. The calculated
annual incidence rate is 1.9 per 100,000 persons
and is based on the average of the population
census figures for 1940 and 1950. If 2 county
residents are included who had the onset of
symptoms during this period but while in the
Service, the rate becomes 2.5 per 100,000. These
rates are noted to he in the range of those re-
ported in studies of other northern cities: Bos-
ton 2.6, Winnipeg 2.2, and Denver 2.2.3

Mortality rate. The average annual reported
mortality rate for Montana for the years 1950
through 1954 is 1.3 per 100,000 persons, and the
corresponding rate for the United States is 1.0.
This degree of excess over the national average
rate was consistently observed in rates deter-
mined for other northern states.3

Case material. Several features characterizing
this group of patients are presented. The women
to men ratio was 18:7. The average age at onset
in the women was 29.3 years, and the average
duration of the disease at the time of the study
was 22.0 years; whereas, in the men, the average
age at onset was 36.1, and the average duration
was 14.9 years. It is realized that these data
from a study of living patients are biased in
favor of a longer duration of the disease and
should not be used alone in predicting life ex-
pectancy. Extreme variation in the severity and

TABLE 2

RECENT STUDIES OF THE PREVALENCE OF MULTIPLE SCLEROSIS IN NORTH AMERICAN CITIES

City and date
of .study

Population at
time of study

Mean temperatures
January July

Latitude

North

Prevalence rate
per 100,000
population

Rochester, 19481

33,000

14

72

44

64

Kingston, 19492

30,000

16

69

44

53

Missoula Co., 1958

42,600

19

68

47

59

AUGUST 1958

359

course of the disease was noted. Two familial
eases were reported — 1 in a sister and 1 in a
cousin. A history of allergic sensitivity was ob-
tained from one-third of the patients. Of a total
of 271 persons, including patients, children of
patients, siblings, parents, aunts, uncles, and
grandparents, rheumatic fever or rheumatic heart
disease was known in only 3 individuals. Patients
reported no suggestive pattern of personal intol-
erance to extremes of weather prior to the onset
of their symptoms. Many complained that cur-
rently extremes of either hot or cold weather
aggravated their symptoms or increased their
degree of disability.

DISCUSSION

Comparisons of the frequency of a disease in dif-
ferent populations provide information about the
natural history of the disease which may help
clarify etiology. The frequency may be expressed
in several ways. The prevalence refers to the
number of persons having the disease at a par-
ticular time, and the incidence and mortality
represent the number of persons who experience
the onset or die from the disease within a given
period of time. These figures are more useful in
making comparisons when expressed as rates —
usually as cases per 100,000 population. Because
of underreporting on death certificates and the
fact that some patients with multiple sclerosis
do not die from this cause, mortality rates de-
rived from death certificates are likely to be de-
ficient. Valid incidence rates are difficult to ob-
tain because of the characteristic insidious onset
of this disease, with the resulting difficulty in
determining dates of onset. For these reasons,
and providing population mobility is slight, the
prevalence rate is thought to be the best esti-
mate of the impact of multiple sclerosis on a
population.

A number of recent studies have provided data
on the incidence and prevalence of multiple
sclerosis in several North American cities. These
studies have added support to the impression
that the prevalence of multiple sclerosis is con-
sistently higher in northern temperate zones
than in subtropical areas and that the frequency
of this disease within these temperature zones
is fairlv uniform. Foreign studies, such as those

REFE

1. MacLean, A. R., Berkson, J., Woltman, H. W., and Schi-

onnem ann, L. : Multiple sclerosis and the demyelinating dis-
eases. Chap. 3: Multiple Sclerosis in a Rural Community.

Baltimore: Williams and Wilkins Co., 1950.

2. White, D. N., and Wheelan, L.: Survey of cases of dissem-
inated sclerosis in the Kingston area. Unpublished paper.

3. Kurland, L. T., Alter, M., and Bailey, P.: Geomedical and
other epidemiologic considerations of multiple sclerosis. Given
at Sixth International Congress of Neurology, Brussels, 19.57.

4. Allison, R. S., and Millar, J. 11. D.: Prevalence and familial
incidence of disseminated sclerosis: report of Northern Ireland

360 THE JOURNAL-LANCET

of Allison and Millar4 in northern Ireland and
Hyllested in Denmark,5 have provided preva-
lence rates which compare well with figures ob-
tained in studies in northern United States and
southern Canada. Within northern Ireland and
all of Denmark, these authors found no local
areas with an undue number of cases. Kurland
and associates found in comparable studies that
the prevalence of multiple sclerosis in Winni-
peg, Boston, and Denver appears to be in the
order of 3 to 6 times greater than in Charleston,
South Carolina, and New Orleans, Louisiana.3-6'7

SUMMARY AND CONCLUSIONS

A study of the frequency of multiple sclerosis
was undertaken in Missoula County, Montana,
to determine whether the clinical impression that
multiple sclerosis was unduly prevalent in this
area was valid. A further intensive epidemio-
logic study would have followed if the frequency
rates had been found to exceed the rates ob-
tained in similar studies of populations living
in a northern climate. The prevalence rate found
in this study of 59 per 100,000 population is
surprisingly similar to those of 64 and 53 per
100,000 found in the Rochester, Minnesota, and
Kingston, Ontario, studies. These 3 studies are
believed to be quite comparable in that they
dealt with small populations, followed similar
methods, and equally thorough attempts were
made to locate all patients in the community.
An average annual incidence rate for Missoula
County was determined, and this is in line with
rates for other cities of comparable climate.

It is concluded that the prevalence and inci-
dence of multiple sclerosis in Missoula County,
Montana, as determined in this study, are con-
sistent with the pattern of rather uniform fre-
quency rates for this disease in widely separated
populations living in comparable regions of cli-
mate in the temperate zone of North America.

ACKNOWLEDGMENT

The clinical impression on the incidence of multiple
sclerosis in Montana was derived from discussions with
Drs. Donald W. Mulder and Henry W. Woltman of the
Mayo Clinic. The authors are grateful for their advice.
The Missoula Chapter of the National Multiple Sclerosis
Society assisted in arranging patient interviews. Drs.
James E. McIntosh and II. Ryle Lewis helped in the
clinical evaluation of some of the patients.

NCES

Hospitals Authority on results of 3-year survey. Ulster Med. J.
(supp.) 23:1, 1954.

5. Hyllested, K.: Disseminated Sclerosis in Denmark, Preva-
lence and Geographic Incidence. Copenhagen: T. Jorgensen

& Co., 1956.

6. Kurland, L. T., Mulder, D. W., and Westlund, K. B.:
Multiple sclerosis and amyotrophic lateral sclerosis. New Eng-
land J. Med. 262:649, 1955.

7. Westlund, K. B., and Kurland, L. T.: Studies on multiple

sclt *rosis in Winnipeg, Manitoba, and New Orleans, Louisiana.
Am. J. Hyg. 57:380, 1953.

Colfax Tornado Disaster

O. M. FELLAND, M.D.
Colfax, Wisconsin

It was 7:00 p.m., June 4, 1958, when our quiet,
peaceful village of 1,000 inhabitants was
struck with one of the most devastating torna-
does ever to have hit this part of the country.

Twelve people were killed instantly; about
60 suffered severe injuries and were hospital-
ized; and another 50 suffered minor injuries,
bruises, lacerations, shock, and so forth. The
entire village and community were stunned.

About one-third of the homes in the village
were destroyed, and many farm sites in the sur-
rounding area were completely demolished.

High tension lines were knocked down, so,
of necessity, the power was shut off. Telephone
service was out. Our village receives its water
supply from a deep well from which it is pumped
into a tank. As several water pipes were broken,
we also lost our water supply. We were, there-
fore, without lights, water, and telephone serv-
ice for the next six or eight crucial hours.

Since I am the only doctor in the village, the
survivors naturally came running to me to help
the injured. After briefly reviewing the situation,
we decided we must have some central station
where we could give temporary first aid to the
victims. Although I have a large office, I realized
it was too small, so it was decided to use the
village auditorium basement. The village police
officer was contacted, and he, with a number of
volunteer helpers, were to bring the injured to
the place designated. A number of cots were
brought in, and I brought a large supply of
first-aid material from my office, such as cotton,
gauze, adhesive, splints, bandages, antiseptics,
morphine, Demerol, and tetanus antitoxin to-
gether with needles and syringes that I keep
sterilized at all times. My wife, who is a grad-
uate nurse, several volunteer workers, and I
were all ready for the patients as they arrived.
We used flashlights at first, but soon someone
brought a gas lantern, which served very well.

At this point, I should like to take you back
a few years. In 1942 and 1943, it was my patri-
otic duty and privilege to give a number of Red
Cross first-aid courses, both elementary and ad-

o. m. felland is a physician and surgeon in Col-
fax, Wisconsin, and is the only doctor in town.

vanced, as part of the Civil Defense Program.
Although we had more or less forgotten about
first-aid and civil defense, on the evening of
June 4, our first-aid courses proved invaluable.
It so happened that many of the rescue workers
who helped the injured out of their ruins and
brought them into our first-aid station had either
taken our first-aid courses or had received such
training while in the service. Those men and
women did a wonderful job. No simple frac-
ture was compounded, and, although 1 patient
had 3 and another 2 broken vertebrae, no pa-
ralysis or injury to the spinal cord resulted.

We have no hospital at Colfax, so those more
severely injured had to be transported to hos-
pitals at Eau Claire, Menomonie, or Chippewa
Falls— all about 20 miles away. We have only 1
ambulance in town, but, fortunately, our police
car is equipped with a radio-telephone, so mes-
sages could be sent to various nearby towns for
ambulances, station wagons, nurses, and doctors.

Our first victims happened to have severe lacer-
ations, but they were able to sit up and be sent
to hospitals in cars. By the time the fracture cases
and those more severely injured arrived, we had
plenty of ambulances and station wagons.

The following is an approximate summary of
the different types of injuries:

About 40 cases of severe lacerations and body bruises.

One crushed foot, requiring amputation of the toes.

One crushed heel.

One fractured tibia.

Three patients with 1 arm broken (radius and ulna).

One patient with both arms broken (radius and ulna).

One badly comminuted fracture at the distal end of
the humerus into the elbow joint.

One fracture of the proximal end of the humerus and
injury into the shoulder joint.

One fracture of the third metatarsal.

Ten patients with several broken ribs.

One patient with very severe lacerations of both legs,
medially and posteriorly, in whom gas gangrene later
developed, but who is recovering.

About 40 patients had minor lacerations, body bruises,
or were simply in shock.

PERSONAL INTEREST STORIES

Two elderly women, aged 55 and 67, were
thrown about 400 feet through the air, and,
besides suffering body bruises, one had only a

AUGUST 1958

361

broken arm and the other had a compression
fracture of 2 vertebrae. Another elderly couple
rode through the air on the floor of their house
and landed in their neighbor’s back yard about
a block away. The man suffered only a trans-
verse fracture of the fifth metatarsal in addition
to a few lacerations on the face and extremities,
and his wife sustained only a broken arm be-
sides a few body bruises and lacerations. One
young lady was thrown up into a tree from
where she was rescued and suffered only a lacer-
ation which required 6 or 7 sutures.

It was clearly evident that we could give only
the most necessary first-aid measures, as, in the
first place, we were handicapped without lights
or water, and, in the second place, I was the
onlv doctor in town during the first hour. How-
ever, the following is a brief summary of the
procedures we tried to carry out:

1. Lacerations were treated with liberal
amounts of antiseptics and were dressed and
bandaged. Bleeding was stopped for the most
part with compression dressings.

2. Fractures were splinted with temporary
splints and adhesive.

3. Those in much pain were given morphine
or Demerol and tagged accordingly.

4. We decided that patients who were to be
hospitalized had best receive their tetanus anti-
toxin and toxoid there, so any reaction they
might have could be observed.

5. As we had no water or light, no attempt
was made to suture any wounds. Those who did
not go to the hospital, but were in need of such
care, came in the following day for treatment.

We were very fortunate, because, in spite of
conditions, no one seemed at all excited. Ev-
erything proceeded just like clockwork. We
had all the severely injured cases in or on their
way to the hospitals within an hour and one-

half. We are indeed indebted to the various
hospitals at Eau Claire, Menomonie, and Chip-
pewa Falls and to the doctors who labored
throughout most of the night as well as to the
ambulances and station wagons that arrived so
promptly and also to Drs. Clauson, Murphy,
and Asplund of Bloomer, who gave their assist-
ance at our first-aid station.

As I write this, two weeks have passed since
our disaster, and only about a dozen patients
are still in the hospitals, and these, I think, will
make good recoveries.

We are also indebted to the National Guard,
who arrived by midnight, to safeguard our vil-
lage and community from curiosity seekers and
looters. The national Red Cross was here the
following morning and is still here doing a
wonderful job in health and rehabilitation.

From my small experience in this type of
work, I believe there are certain conditions
which are very desirable in case of such emer-
gencies, and I would recommend the following:

1. Have a central place equipped with the
necessary cots, stretchers, blankets, and so forth,
where all the injured can be taken.

2. Have efficient help trained and ready for
such emergencies, and see that each person, or
group, has a specified, prearranged job to do.

3. Have plenty of first-aid supplies on hand
at the doctor’s office or at the first-aid station.

4. II ave on hand emergency lighting facili-
ties—lanterns at least.

5. Have a water supply available that is in-
dependent of the regular city water. In our
case, one of my sons brought in water pumped
from a well on the other side of town.

6. Perhaps the most important equipment that
every little village should have is a radio-tele-
phone, such as our police car has, in order to
contact surrounding communities for help.

362

THE JOURNAL-LANCET

Edward E. Novak, M.D.

Pioneer Doctor, Educator , Financier ,
and Animat Husbandry Expert

J. ARTHUR MYERS, M.D.

EE. Novak was born April 29, 1873, in Johnson
• County near Iowa City. He attended rural
school and graduated from the Iowa Citv Academy
in 1892. He received the degree of Doctor of Medi-
cine from the University of Iowa in 1895, and the
same year began the practice of medicine in New
Prague, Minnesota, which he has continued for the
past sixtv-three years.

Through all of these years, he has rendered ex-
cellent medical service to the citizens of New
Prague and the surrounding countryside. He has
delivered thousands of babies, many of whom are
now in the upper age brackets of life. He has
brought large numbers of people of all ages through
serious illnesses. He has brought comfort to many
families by relieving the suffering of those in the
family with incurable conditions. He has always
been quick to adopt preventive measures of proved
value, such as immunization for diphtheria and
smallpox.

Dr. Novak is so modest that it was difficult to
obtain the desired information concerning his ac-
tivities and contributions for this biographic sketch.
Therefore, correspondence was not effective. How-
ever, this problem was solved when a dinner was
arranged at the home of Mr. and Mrs. C. W. Loufek,
his sister and brother-in-law, in Minneapolis on
May 30, 1956. Following the dinner, three of his
close friends engaged him in conversation by asking
numerous questions about his life and work. To
these he responded freelv. After more than two
hours of conversation, which we always directed
back to his work, he was informed that one of these
friends, Dr. Charles E. Proshek, had a tape recorder
in continuous operation. He then had the opportu-
nity of listening to the record and permission was
given to use as much of the information as space

would permit. This record contains so much val-
uable information, historically and otherwise, that
it has been suggested that it be presented to the
State Historical Society.

Dr. Novak is a firm believer in providing the best
possible educational facilities and has devoted a
tremendous amount of time to schools and school
children. He was a member of the New Prague
Board of Education for forty-four years and was its
president from 1920 to 1951. He was president of
the Five Town County School Board Associations
for five years and president of the Minnesota State
School Board Association from 1935 to 1936. He
received the Distinguished Service Award of the
Minnesota Education, National School Service In-
stitute in 1944.

He was “father” of Minnesota’s income tax law,
earmarking income tax funds for school purposes.

He is a lifetime supporter of higher education
and has rendered valuable service to the University
of Minnesota by serving as a member of its Board
of Regents from 1937 to 1955.

His activties in local civic affairs were cause for
election to mayor of New Prague for two terms at
the turn of the century. From 1917 to 1919, he
was president of the New Prague Lincoln Club
and, from 1919 to 1924, president of the New
Prague Community Club.

In 1930, he was LeSueur County Democratic
chairman and Democratic presidential elector in
1932. Four years later, he was drafted as candi-
date for Democratic nomination for governor of
Minnesota.

He is a founder (1903) and a former vice presi-
dent of the First National Bank of New Prague
and has been president of the State Bank of New
Prague since 1936.

AUCUST 1958

363

Having been reared on a farm in Iowa, Dr. Novak
has much firsthand information concerning agricul-
ture and, particularly, animal husbandry. In 1950,
he published an article in which he stated that
the livestock industry loses $100,000,000 annually
because of animals that are infected with brucel-
losis. He pointed out that 5 to 8 per cent of the
cattle in the United States were infected with this
disease, and it was estimated that 10 per cent of
the American people show evidence of brucellosis
infection. It was estimated that for every clinical
case diagnosed, there were at least 8 to 10 non-
clinical or mild cases never correctly diagnosed.
In this most enlightening article, he called attention
to the great destruction caused by brucellosis not
only in animals but also in man and gave the most
detailed diagnostic procedures and prophylactic
measures. He paid tribute to the fine work that was
developed and carried through at the University of
Minnesota. His article ended with the following:
“The writer is sincerely convinced that what was
accomplished in eradicating tuberculosis in our cattle
through area testing and slaughter can, with similar
methods, be achieved in eradicating brucellosis.”

He was a founder of the New Prague Creamery
Association of which he was president from 1912
to 1926. At the local creamery, he arranged for the
Bang Ring Test, which revealed that 34 per cent of
the dairy herds of the area served had brucellosis.
Without methods to eradicate the disease at that
time, he labored long to have pasteurization intro-
duced before he succeeded.

There is no doubt that the role Dr. Novak played
in the fight against brucellosis in cattle and human
beings contributed mightily to the rapid control of
the disease, so that, by 1954, Minnesota was one of
the three states to have reduced brucellosis in cattle
to 1 per cent or less and, thus, receive the classifi-
cation of Modified-Certified Brucellosis-Free state.

Dr. Novak was an intimate friend and firm sup-
porter of the work of Charles E. Cotton, who par-
ticipated in the first testing of cattle with tubercu-
lin in this country in 1892. Dr. Cotton administered
the tuberculin test to numerous cattle in the vicinity
of Minneapolis in 1893 and 1894 and was influential
in having the first ordinance in the world passed
regulating the production of milk within the limits
of a municipality. This was in 1895, the year Dr.
Novak began to practice in New Prague. Immedi-
ately, Dr. Novak came to Dr. Cotton’s assistance and
helped to promote tuberculin testing everywhere, so
Minnesota received the rating Modified- Accred-
ited Tuberculosis-Free area in December 1934. This
permitted )'i of 1 per cent of reactor animals in an
area at any testing. Therefore, much remained to
be done after the state was modified-accredited be-
fore the eradication goal could be reached. From
1934 to the present. Dr. Novak has continued to
promote periodic tuberculin testing of cattle. The
eradication goal is not quite attained, but now the
testing of 5,000 cattle is required to find 1 reactor
in Minnesota.

On June 28, 1956, Dr. Novak wrote: “I always
admired Dr. Cotton very much. He was a great
inspiration to me in helping his cause wherever an
opportunity presented itself. Well do I remember
some ol the local as well as state meetings where
health problems were considered — especially tuber-
culosis and brucellosis. Many a time the decision
was in the balance, and he called for assistance
from the human side of problems, and it was a great
pleasure and privilege to try to explain the need to
eradicate tuberculosis and Bang’s bacillus, both be-
ing the source of infection of humans.

“As a bov on the farm I was the ‘doctor’ for the
animals on my father’s farm, and I suppose that is
why my mother and older brothers thought it proper
for me to study medicine. So I took their advice.”
Since childhood. Dr. Novak has been interested in
purebred cattle and thoroughbred horses. He is
owner of the Redvue Farms at New Prague, where
he has produced large numbers of purebred Red
Polled cattle, many of which have won coveted na-
tional honors, including 3 National Grand Cham-
pion Sires. He has long been an active member of
the Red Polled Cattle Club of America, which he
served as president from 1932 to 1952. In 1952,
this organization’s Distinguished Service Award was
bestowed upon him.

He was a founder of the Southern Minnesota
Livestock Show and president from 1922 to 1938.
He instituted and promoted this show to convince
farmers of the value of replacing their grade animals
with purebred stock. Dr. Novak saved a group of
buildings from being wrecked by gaining possession
of the property by paying the delinquent taxes of a
bankrupt machine factory. He then turned this
property over to the Southern Minnesota Livestock
Show for housing facilities. When the livestock show
was discontinued because of economic conditions in
1941, these housing facilities became the home of
the Minnesota Valley Breeders Association. He takes
pride in having helped to organize this association,
since it is the second largest organization of its kind
in the United States. It is doing fine research in the
field of artificial insemination and also in pointing
the wav for easier and better ways of caring for and
feeding livestock.

In 1895, when Dr. Novak located at New Prague,
the population of the village was 700. There was no
telephone. Like Dr. Novak, the townspeople did
not work by the clock but until the job was done.
The few farmers in the vicinity had to clear the
land largely with hand saws, axes, and grubbing
hoes. Little by little the cleared, fertile soil pro-
duced wonderful crops. Having been reared on a
farm in Iowa, where such clearing of land was not
necessary, Dr. Novak was well-informed on the most
modern methods in successful agriculture. He dem-
onstrated these methods on his own farm, which, at
first, seemed ridiculous to other New Prague pioneer
farmers, but they graduallv realized that his rota-
tion of crops, including the growing of alfalfa, and
his practice of raising onlv purebred animals and

364

THE JOURNAL-LANCET

keeping them tree from such diseases as tuberculosis
and brucellosis by having them tested two or three
times each year were far more economical than the
methods they employed. Thus, he taught the entire
countryside the best methods in agriculture of the
day. His influence among the farmers, no doubt,
was largely responsible for the area’s development
of such a fine record in crop growing and animal
husbandry. Indeed, it was Dr. Novak who, as an
individual farmer, shipped to market the first carload
of hogs from New Prague.

In those pioneer davs, the practice of medicine
was difficult from the standpoint of transportation
and the sparse population in the country. Dr. Novak
walked to make many calls among the villagers.
In the summer, he rode a bicycle. After practicing
about two years in New Prague, he found the need
of better transportation facilities. He went back to
Iowa, and his father gave him a Hambletonian colt.
“Good horses and equipment made rural practice
a pleasure.” In the winter, he drove horses hitched
to wagons, sleighs, sleds, buggies, and, not infre-
quently, he traveled on horseback. He was always
ahead of his time as manifested in so many ways,
one being that he owned the first automobile in
New Prague in order to respond more promptly to
the calls of patients.

Epidemics, including smallpox, scarlet fever, diph-
theria, and other communicable diseases were fre-
quent in the beginning of his practice. Diphtheria
antitoxin was not available for several years. As
soon as diphtheria immunization was considered ef-
fective and practical, Dr. Novak led the campaign
for immunization in the schools. He has always
firmly believed and taught that physicians should do
work involving the health of the public gratis or at
a minimum cost in order that all may benefit.

Tuberculosis was a terrible scourge in Minnesota
in 1895. That year the mortality rate was 110.6
per 100,000; 1,693 people died. He saw the rate
rise to 119.7, when 2,522 deaths occurred in 1911.
Dr. Novak continues to be a potent force against
this disease. He has advocated and promoted tuber-
culosis eradication programs in the schools through
tuberculin testing, isolation of contagious cases, and
dissemination of information among people every-
where. He is a versatile speaker, well-informed be-
fore he speaks and always manifests the courage of
his convictions. He played an important role in
decreasing the tuberculosis mortality rate to 3.1,
when only 101 died in 1957.

The medicine he has practiced has always been
the best at the time. “1 tried to cultivate in our
community the need of a hospital as I soon recog-
nized the need of such an institution. In 1906, I

tried to get financial aid to build a small hospital
but did not succeed. Later, I secured four additional
rooms over the Hemes’ Drug Store, where my office
was then located, and equipped them as operating
rooms, etc., with two beds. This served us quite well
for ordinary surgical cases up to about 1932. At this
time, Mr. Harvey, one of the officers of the Inter-
national Milling Company, moved to Minneapolis,
and we inherited his fine residence as a community
hospital, which served us well indeed until our pres-
ent Memorial Community Hospital was built.”

Not only is Dr. Novak a constant reader of med-
ical books and journals, but he attends medical
meetings regularly. He takes an active part in the
medical organizations to which he belongs, such as
countv, state, and American medical associations.

Dr. Novak speaks of the two “vacations” he has
had in sixty-three years of practice. These were for
six months each, one in 1913 and the other in 1932,
but most of the time was spent attending clinics at
the University of Prague, Czechoslovakia. In April
1958, he went to Rio de Janeiro, Brazil, where his
daughter and her husband are representatives of the
United States government in the radio field.

He has been a staff member of the Community
Memorial Hospital in New Prague since 1924 and
of the Valiev View Hospital at Jordan, Minnesota,
since 1952. His contributions have been so great
and have extended over so many years that the
Minnesota Medical Association named him Minne-
sota Physician of the Year in 1954.

When he had practiced in New Prague for fifty
years, a testimonial banquet was given for him on
April 29, 1945. It appeared that the entire com-
munity of New Prague and surrounding country had
arrived for the banquet and program which fol-
lowed. Many who arrived could not be accommo-
dated for lack of space. That day a fine editorial
appeared in the Minneapolis Star entitled “Country
Doctor.” After relating his numerous activities and
contributions, the editorial concluded as follows:
“. . . but New Prague probably reveres him most
as a country doctor — the man who has come at
many calls to deliver babies and see oldsters out
of this world. This evening his neighbors are gath-
ering at a dinner to celebrate the fiftieth anniversary
of his arrival in New Prague. They hope his shingle
will swing in the wind of southern Minnesota for
decades more."

At the age of 85, Dr. Novak continues to prac-
tice most modern medicine, not onlv in his office
but also in homes and hospitals. In addition, his
counsel is sought in such fields as agriculture, edu-
cation, banking, and, best of all, as a close, personal,
true friend.

AUGUST 1958

365

Cancet

CLINICAL

REVIEWS

Surgical Repair of
Incomplete Cleft Lips

THADDEUS J. LITZOW, M.D.
Rochester, Minnesota

Fig. 2 a and b. Previously repaired left cleft lip. Tlie
patient sought correction of the nasal and lip deformities,
(c and d). Appearance after rhinoplasty for nasal de-
formity and repair of upper lip as discussed in text.
Upper lip has been lengthened.

f^r^iiE Le Mesurier' operation has been gen-
J. erally accepted as an excellent procedure
for the repair of unilateral complete clefts of the
lip. By the use of a quadrangular flap (figure
1), it corrects the objectionable straight-line scar
of older methods (figure 2a). The quadrangular
flap restores the cupid’s bow and the natural pout
of the lower portion of the upper lip. Last, the
procedure corrects the congenital shortness of
the cleft side of the lip. Older methods frequent-
ly failed to achieve these advantages of the Le
Mesurier procedure.

The most prominent deformity of an incom-
plete cleft lip is the notching of the lower por-
tion of the upper lip. Closer inspection usually
reveals a vertical groove on the skin surface ex-
tending from the vertex of the notch into the
base of the nostril on the same side (figure 3a).
This groove represents a failure ot normal de-
velopment of the underlying mesodermal struc-
tures and is manifested by a deficiency ot the
muscular structures of the upper lip in this re-
gion. The lip on the cleft side is also shorter as
compared to the normal length of the lip on the

tuaddeus j. litzow is a member of the Section of
Plastic Surgery at flic Mayo Clinic.

366

THE JOURNAL-LANCET

This department of The Journal-Lancet is devoted to reports on
cases in which all the appropriate diagnostic criteria have been
employed, the best known treatment administered and the results
recorded. It is desired that these case reports be so prepared that
they may be read with profit by physicians in general practice,
hospital residents and interns and may be of considerable value to
junior and senior students of medicine. This department welcomes
such reports from individuals or groups of physicians who have
suitable cases which they desire to present.

unaffected side. The nose on the same side of
the cleft is deformed by widening of the nostril
and flaring of the ala. An acceptable surgical
plan for closure of this type of cleft must include
correction of the entire deformity of the lip and
nostril (figure 3b).

The Le Mesurier procedure, as outlined for
complete cleft lips, is not directly applicable to
incomplete clefts, especially the smaller clefts.
Modification of this procedure, as outlined by
Brauer2 in 1953, has been satisfactorily applied
to our cases of primary incomplete cleft lips and
secondary repair of cleft lips (figure 4). This
method also avoids the straight-line scar and
gives the needed additional length to the cleft
side of the lip. Again, the quadrangular flap re-
stores the cupid’s bow and the natural pout of
the lower portion of the upper lip (figure 5).
The method can be applied equally well to the
primary repair of small clefts in adults, as seen
in figure 3.

Patients seeking secondary repair of operated
cleft lips usually have an unsightly linear scar
with notching and shortness of the lip.

The patient seen in figure 2 requested correc-
tion of his nasal deformity and improvement of
his lip if it were feasible. The nose was correct-
ed as shown in figure 2c and (l. The notching
associated with the vertical scar and the shorten-
ing of the lip were then corrected by the method
under discussion.

A modification of the Le Mesurier procedure
encompassing the advantages of the original
plan has been successfully applied to the pri-
mary repair of incomplete clefts and secondary
correction of unsightly repaired cleft lips.

REFERENCES

1. Le Mesurier, A. B.: Treatment of complete unilateral hare-

lips. Surg., Gynec. & Ohst. 95:17, 1952.

2. Brauf.r, R. O.: Consideration of Le Mesurier technic of single
harelip repair with a new concept as to its use in incomplete
and secondarv harelip repairs. Plast. & Reconstruct. Surg. 11:
275, 1953.

Fig. 3 a. Primary incomplete left cleft lip in an adult.
(b). Early postoperative result. Sutures had been re-
moved the previous day.

Fig. 4. Modification of the Le Mesurier procedure for
incomplete cleft lip.

Fig. 5a. Incomplete left cleft lip with associated nasal
deformity. ( b ). Appearance five months after operation.

AUGUST 1958

367

High Arterial Pressure, by F. H.

Smirk, 1958. Springfield, Illinois:

Charles C Thomas. $15.00.

This volume consists of 764 pages
with a generous bibliography at the
end of each chapter. The author ap-
pears to cover well the physiologic,
pharmacologic, and experimental
aspects of the subject as well as the
basic clinical entities of hyperten-
sion. Thus, endocrine, renal, and
psychosomatic factors are included.
Drugs, past and present, are dis-
cussed under therapy, and there are
277 references to hypotensive drugs
which are classified chiefly as of
academic interest. Consideration of
the pharmacology of ganglion block-
ing agents, including hexamethonium
and pentomethonium, is followed by
an extensive discussion of the treat-
ment of patients with such agents
and with other combinations, in-
cluding the Rauwolfia compounds.
This book will be a valuable addi-
tion to the internist’s library or to
that of any physician interested in
the blood pressure problem.

C. A. McKinlay, M.D.

The Atomic Age and Our Biological
Future, by H. V. Brondsted,
1957. New York: Philosophical
Library, 80 pages. $2.75.

The purpose of this book is to dis-
cuss in a simple manner the effects
of radiation on man. The author’s
principal concern is with the pos-
sible effects of atomic energy on
man’s genetic constitution.

After a discussion of the physics
of radiant energy and of the con-
stitution of cells, the author pre-
sents a factual and interesting pic-
ture of the interaction of radiation
and matter. His model of living
cells as 1 kilometer diameter spheres
containing colored marbles (atoms)
and knotted ropes ( genes in chro-
mosomes ) will assist the uninitiated
in understanding how some of the
effects of radiation take place.

The author’s terminology may be
questioned in several instances. He
refers to millicuries of radioactivity
in terms of “energy” liberated and
defines the roentgen unit as
“strength” or “energy” of radiation.
Strictly speaking, both of these
units are measurements of quantity
only. He also misuses the term
“power” where “force” is actually
implied. In chapter 4, the discus-
sion of maximum permissible dose
is not in accordance with the pres-
ent recommendations of the Inter-
national Committee on Radiation

BOOK

REVIEWS

Protection (ICRP). It recommends
that occupational exposure of in-
dividuals be restricted to an aver-
age of 5 rem ( or roentgens ) per
year, and that the exposure of the
general population should on the
average be less than one-tenth of
t his amount. Brondsted states in
Chapter 6 that the approximate ex-
posure from radioscopy ( fluoros-
copy ) is 30 r. per minute. This
might be true in Denmark, but, ex-
cept for isolated instances, com-
parable machines in this country are
restricted to deliver less than 10 r.
per minute in accordance with the
National Bureau of Standards Hand-
book 60 on “X-ray Protection.”
Also, the author’s sweeping state-
ment that further hydrogen bomb
testing is unjustifiable because of
the “great quantities of powerfully
radioactive strontium isotope Sr90
produced,” is to be questioned.
Radioactive strontium is not formed
in the fusion reaction. Some Srnn
will be formed, however, if the fis-
sion process is used to trigger the
fusion reaction.

In summary, an interesting and
logical picture of “The Atomic Age
and Our Biological Future” has
been presented. This book is recom-
mended for those who desire infor-
mation on the effects of radiation
on man.

Merle K. Loken, Ph.D.

Human Perspiration , by Yas Kuno,
M.D., edited by Robert F. Pitts,
M.D., 1956. No. 285, American
Lecture Series, monograph in
Bannerstone Division of American
Lectures in Physiology. Spring-
field, Illinois: Charles C Thomas;
Oxford: Blackwell Scientific Pub-
lications, Ltd.; Toronto: Ryerson
Press, 416 pages. $9.50.

Dr. Kuno, one of the world’s pioneer
physiologists, and his associates have
spent more than thirty years in their
studies of the anatomy, physiology,
and biochemistry of the sweat ap-
paratus. The results of these efforts
are presented in this monograph,

which represents the most authori-
tative and comprehensive work on
human perspiration now available.

Included in the 13 chapters are
detailed discussions of insensible
perspiration, anatomy, physiology,
and evolutionary development of the
sweat apparatus, regional and gen-
eral sweating, chemistry of sweat ac-
climatization, and the significance of
sweating. There is also an extensive
appendix in which the author deals
with research methods for the meas-
urement of perspiration. Since Dr.
Kuno has not attempted to present
a complete review of the literature,
but rather the results of his own
studies, the short bibliography of
selected references is entirely ade-
quate and provides valuable refer-
ence material. The book is well illus-
trated throughout, and there are
many excellent tables and diagrams
to enhance the value of the author’s
descriptions. It is a welcome addi-
tion to the growing literature on hu-
man perspiration and belongs in the
library of every dermatologist.

Elmer M. Hill, M.D.

Hijpophysectomij, edited bv O. H.
Pearson, M. D., 1957. Spring-
field, Illinois: Charles C Thomas,
154 pages. $5.00.

This small book is a report of the
proceedings of a conference held at
the Sloan-Kettering Institute, New
York City, March 19 and 20, 1956.

At this meeting, 24 participants
discussed the removal or destruc-
tion of the hypophysis for the treat-
ment of carcinoma of the breast and
for a few tumors of other origin,
such as diabetes mellitus.

The technic of several different
approaches to the pituitary fossa
make it quite obvious that the usual
approach used for pituitary tumor
surgery is not satisfactory and must
be modified in order to adequately
expose the pituitary fossa for total
removal of the gland.

Several speakers referred to re-
moval of the anterior clinoid process,
but it is doubtful whether anyone
has actually removed the anterior
clinoid process. It is true that some
do remove the medial clinoid proc-
esses.

Dr. Luft reported 37 cases of
hypophysectomy for cancer of the
breast and concluded that patients
who responded unfavorably were
over 60 years of age, had metastases
to the nervous system or extensive
liver metastases. However, Ray and
Lipsett reported 10 of 18 patients
(Continued on page 18A)

368

THE JOURNAL-LANCET

More than
enough
Gantrisin
Tablets
to encircle
the earth-

If all the Gantrisin tablets* produced and used
since the introduction of this single, soluble
sulfonamide were placed "end to end,” the distance
would exceed 24,000 miles — more than enough to
encircle the globe at the equator.

This acceptance by the medical profession is
overwhelming evidence of the clinical usefulness,
efficacy and safety of Gantrisin.

*More than 3 billion tablets (liquids and other
forms not included).

GANTRISIN® — brand of sulf isoxazole

Original Research in Medicine and Chemistry

ROCHE LABORATORIES

Division of Hoffmann-La Roche Inc

Nutley 10, N.J

BOOK REVIEWS

( Continued from page 368 )

over 60 years of age who did re-
spond favorably.

Kennedy selected patients for op-
eration using the following criteria:

1 . The premenopausal woman
who improves after therapeutic
castration.

2. The woman who undergoes
spontaneous menopause at the time
of recurrence and slowly progresses.

3. The postmenopausal woman
who responds to estrogen or andro-
gen hormones.

It was also suggested by Pearson
that a woman in whom exacerbation
of carcinoma of the breast occurs if
given estrogen could be expected to
respond, but he did not advise at-
tempting the operation because of
possible serious consequences.

Both Ray and Matson found that
if the pituitary stalk is preserved
without trauma, diabetes insipidus
is less apt to develop.

Since hypophyseetomy for car-
cinoma of the breast has only been
done recently, most of the reported
cases had not been followed for
long periods, and survival is re-
ported in months rather than years.
Ray reported the average survival
of 36 patients who did respond to
be 9.3 months, but 21 of them were
still living.

The indications for hypophy-
seetomy in diabetes are not yet
settled. Luft reported that the pro-
cedure appeared to arrest the pro-
gressive retinopathy and new aneu-
rysms did not develop, but intra-
ocular hemorrhages did continue to
occur, although less frequently.

Physiologic effects of hypophy-
seetomy are discussed. The pre-
menopausal woman has prompt
cessation of menses. Hypothyroid-
ism develops. Ability to conserve
sodium is not disturbed, apparently
because of continued aldosterone
secretion. Diabetes insipidus oc-
curred in most patients.

The final section of the book con-
cerns radiation hypophyseetomy.
Various types of irradiation have
been used, but, in general, irradi-
ation failed to destroy the hypophy-
sis as completely as surgery; the
therapeutic results were not as good;
and the incidence of injury to the
optic nerves or other intracranial
nerves was disturbingly high.

This book should be of value to
internists and general practitioners
who wish to know what can be ac-
complished by hypophyseetomy.

William T. Peyton, M.D.

Liver- Brain Relationships, by I. A.
Brown, M.D., 1957. Springfield,
Illinois: Charles C Thomas, 176
pages. $6.50.

This small volume consists primarily
of a summary of our present knowl-
edge concerning the relationship be-
tween the function of the liver and
brain. Its unique feature is that it
has been written by a neurologist
rather than an internist. A good
share of this volume is devoted to a
review ol the literature on the liver-
brain inter-relationship covering va-
rious aspects of the clinical manifes-
tations, the pathologic changes, and
the biochemical alterations involved.
The author includes a study of 82
cases ol liver disease in which 40
died in hepatic coma, allowing for
complete autopsy studies. On the
basis ol these cases, the author re-
capitulates the clinical manifesta-
tions of the cerebral involvement
and the variation in the central nerv-
ous system changes. This volume is
concluded with some speculations
on the possible biochemical changes
that could be implicated in the liver-
brain process and the concept that
probably not one but many biochem-
ical alterations are involved.

Although presenting no new ma-
terial, this small volume does offer
an excellent review of the subject
in a clear, concise fashion.

A. B. Baker, M.D.

•

The Human Ear Canal, by Eldon
T. Perry, M.D. A monograph in
the Bannerstone Division of
American Lectures in Derma-
tology, edited by Arthur C.
Curtis, M.D., 1957. Springfield,
Illinois: Charles C Thomas, 116
pages. $4.75.

It is generally agreed that the study
and treatment of the human ear
canal is usually assumed by the
otologist, but certainly it is likewise
felt that the dermatologist, because
of his greater familiarity with skin
diseases in general, is much better
equipped to cope with many ol the
skin problems relating to the human
ear. This monograph, as the author
states in the introduction, is “a
dermatologist’s eyeview of the hu-
man ear canal.”

The author devoted two years to
detailed study and investigation of
this subject. In this volume, he re-
ports his findings and conclusions.
That the literature on external ear
disease has been carefully reviewed
may be attested to by the complete
bibliography appended to each

chapter. The essential facts concern-
ing the gross and microscopic
anatomy of the ear canal and its
appendages— the ceruminous glands,
the sebaceous glands, and the hairs
—are well presented and illustrated.
In addition, a report of original in-
vestigations concerning the forma-
tion and stimulation of flow of ceru-
men by the ear canal is given in
detail. This work was carried out on
inmates of penal institutions and
hospital employees. At the same
time, a careful analysis of the nor-
mal and abnormal resident bacteria
and fungi found in the ear canals of
the volunteer subjects, with and
without external otitis, was made.
Original work in the physiology of
the excretory glands was also car-
ried out. The cerumen of the hu-
man ear is a mixture of the secretory
products of the sebaceous and ceru-
minous glands. The author found
that the secretion of the ceruminous
glands resembles that of the apo-
crine sweat glands of the axilla.
These glands both respond to the
same stimuli: pain, emotion, anxiety,
fear, adrenergic drugs, and me-
chanical stimulation.

The chapter describing the
clinical picture of external otitis is
very well done. It presents a
broader and more comprehensive
view of external otitis than the gen-
eral physician or otolaryngologist
usually considers. For instance, a
differential diagnosis of this con-
dition discusses: furunculosis, se-
borrheic dermatitis, contact derma-
titis, neurodermatitis, pyoderma, in-
fectious eczematoid dermatitis, cellu-
litis, psoriasis, chronic discoid lupus
erythematosis, hot weather ear, and
epthelioma. This dermatologic ap-
proach to a correct diagnosis seems
logical. A diagnosis of external otitis
is not enough. One must consider
the foregoing conditions.

In 6 short pages, the author gives
very sketchy and incomplete direc-
tions regarding general principles
and specific treatment for the con-
ditions listed under differential
diagnosis. In my judgment, it would
be very difficult for a young inex-
perienced physician in general prac-
tice to read this chapter and feel
that he coidd properly care for a
patient with external otitis.

Excluding the chapter on treat-
ment, I found this book very well
worth reading. It contains much
valuable information regarding the
human ear canal, especially from
the dermatologist’s viewpoint.

George M. Tangen, M.D.

18A

Y ^ i

Journal

\'nx\ rot"

I ^-i III I SERVING THE MEDICAL PROFESSION OF MINNESOTA,

W/W' V NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

A Study of Femoral Head
Replacement Prostheses

GEORGE M. HART, M.D.
Minot, North Dakota

During the past five years, 23 femoral head
prostheses have been inserted in 22 patients
in the orthopedic section of the Northwest Clinic.
In December 1957, a follow-up study was made
on 20 patients who had been operated upon
prior to that time.

Six different tvpes of prostheses have been
used, including 8 metal Judets, 3 metal Judets
with skirt extensions, five Eichers, 1 acrylic
Judet with skirt extension, 1 Naden-Rieth, and
5 vitallium Moores (figure 1). At the present
time, the vitallium Moore is the prosthesis of
choice. Several difficulties experienced with
tvpes previously used have led to a search for
one that is more satisfactory. Three complica-
tions that occurred in patients in whom metal
Judet prostheses were used were: (1) rotation
of the appliance and its stem in the trochanteric
and subtrochanteric region of the femur with
associated pain; (2) settling of the prosthesis
on the neck of the femur with lateral protrusion
of the stem; and (3) upward shifting of the stem
in the trochanteric region following gradual
bone erosion superior to the stem, allowing the
prosthesis to assume a position of varus. In
patients in whom settling of the appliance took
place, the stem protruded laterally from 1 to
2 cm. Over this protruding stem, a bursa de-
veloped with associated tenderness and pain

George M. Hart is consultant in orthopedic surgery
at Veterans Hospital, Minot, and on the staffs of
Trinity Hospital and the Northwest Clinic, Minot.

over the lateral trochanteric region. In 1 pa-
tient, this pain was sufficiently severe to require
removal of the protruding portion of the stem.
No further settling occurred afterwards, and the
patient’s compaint was relieved.

The chief difficulty with the Eicher prosthesis
was in preparing the bed for the prosthesis stem
in the shaft of the femur. Due to the size and
shape of the Eicher stem, a rather wide bed
must be prepared with the Eicher rasp. Con-
siderable cortical bone has to be removed,
which is a difficult procedure. In 2 patients in
whom Eicher type of prostheses were used, the
shaft of the femur was fractured during their
insertion. Another difficulty with the Eicher type
has been fracture of its stem. Although this com-
plication did not occur in any of the patients
in whom an Eicher prosthesis was used in this
series, 1 patient was seen in consultation in
whom it did occur. The original injury had in-
cluded a fracture of the acetabulum, permitting
the prosthesis to be seated deeper than usual in
the acetabulum. Motion of its head was re-
stricted, which produced excessive strain on the
stem.

Metal Judet prostheses with skirt extensions
were used in 3 patients as compared with 8 in
whom the standard metal Judet was employed.
In these 3 patients, no femoral neck remained
and the prosthesis with the skirt extension was
used to provide greater distance between the
trochanteric region and the head of the femur.
Patients with an inadequate femoral neck lose

Fig. 1. Various types of femoral head replacement pros-
tlieses. Left to right (above): acrylic Judet, acrylic Judet
with skirt extension; (below): metal Judet, metal Judet
with skirt extension, Naden-Rieth, vitallium Moore,
Eicher, and Minneapolis.

active abduction of the hip as the line of pull of
the abductor muscles on the greater trochanter
approaches 180 degrees with the shaft of the
lemur.

An acrylic Judet prosthesis with skirt exten-
sion was used in 1 patient. However, because
of frequent reports of erosion and fractures, its
use was not continued.

INSERTION OF THE PROSTHESIS

Several surgical approaches have been used for
insertion of prostheses. In the 23 operations
which have been performed up to this time, an
anterior approach was used in only 3 instances.
A posterolateral approach was used in all the
rest. In the earlier cases, the posterolateral ap-
proach described by Gibson1 was used in which
the gluteus maximus was reflected medially and
distally along its upper border, and the gluteus
medius and minimus were sectioned at their in-
sertion into the greater trochanter and then re-
flected anteriorly and proximally. In the more
recent cases, the approach described by Austin
Moore2 has been used in which the fibers of the
gluteus maximus are separated about 1/2 in. above
the lower border of the muscle. The sciatic nerve
is identified and retracted medially. The gluteus
medius is no longer sectioned but is retracted
anteriorly to expose the posterior rotators of the
hip which are divided at their insertions. The
capsule is opened and, after insertion of the
prosthesis, resutured whenever possible.

Some difficulty lias been experienced with this
approach, particularly in hips in which the cap-

sule is considerably scarred. In several cases
with scarred, contracted capsules, the gluteus
minimus and medius have been divided as in
earlier procedures. However, ambulation can be
started earlier if the gluteus medius is left intact.

Postoperatively, patients were jilaced in bal-
anced suspension for ten days to three weeks,
depending upon whether or not the gluteus
medius had been sectioned. Ambulation was
then started by the physiotherapist, beginning
with active exercises of the hip, thigh, and knee
and progressing to walking between parallel bars
and, finally, to crutches.

In earlier cases, crutches were discarded for a
cane as soon as the jiatient gained sufficient
strength. However, more recently, following the
advice of Austin Moore, weight bearing has been
deferred to allow strengthening of the cortical
bone beneath the jnosthesis.

INDICATIONS FOR USE OF FEMORAL HEAD PROSTHESES

In this series, fracture of the femoral neck with
nonunion has proved to be the most frequent
indication for insertion of a femoral head juos-
thesis. Of the 23 hips operated upon, 15 have
had nonunion of intracapsular fractures. De-
generative arthritis was an indication for surgery
in 4 of them. In 1 of these patients, the degener-
ative arthritis was due to a congenital dysplasia
of the hips and both were operated upon. One
of them with degenerative arthritis had an asso-
ciated fibromyxoma of the upper femoral neck
and head.

In 1 patient, the indication for surgery was
ankylosis of the hip joint after sej^tic arthritis.
The original problem in this patient had been an
acute slipped capital femoral epiphysis. Oper-
ation had been performed elsewhere and was
followed by infection. One patient had a healed
fracture of the femoral neck with aseptic necrosis
of the head. The youngest patient in this series,
a 13-year-old boy, had a slipped epiphysis of two
years’ duration with comjilete destruction of the
head and neck. The parents of this child were
Christian Scientists and refused to seek medical
care until the head and neck had been com-
pletely destroyed.

CONTRAINDICATIONS FOR USE OF
FEMORAL HEAD REPLACEMENT PROSTHESES

Several contraindications have been formulated
for the use of femoral head prostheses. Acute
fractures of the femoral neck are still treated in
this clinic by internal fixation rather than by re-
placement of the head with a prosthesis. One
exception was made in a mentally confused in-
dividual. Patients who are voting and have the
greater portion of their vears ahead of them are

370

THE JOURNAL-LANCET

generally not thought to be good candidates for
prostheses. Arthrodesis, when possible, is felt to
De preferable in young patients. In general, re-
sults have been poorer in patients in whom pros-
theses have been inserted tor arthritis ot the hip
than in those who were treated for nonunion or
the femoral neck. To qualify for a prosthesis, a
patient with an arthritic hip should De unable to
walk preoperatively without crutches or, at least,
a cane and should fully understand the situation
before surgery is carried out. Patients with
rheumatoid arthritis probably are not good candi-
dates for femoral head replacement prostheses.

FOLLOW-UP STUDY

The age of patients in this series ranged from 13
to 81 years. The average was 63 and the median
68 years. Fifteen of the 22 were women, and 7
were men. Of the 23 hips operated upon, the left
side was involved 14 times and the right 9 times.

A follow-up study was made in December
1957 on the 20 patients operated upon up to that
time. The average time elapsed postoperatively
in this study was 25.7 months with the longest in-
terval 59 months and the shortest 2 months. The
study was made by examination in a number of
cases and by a questionnaire mailed to patients
who were unable to come in for re-examination.
Of the 20 patients, 35 per cent were walking un-
aided with neither a cane nor a crutch. Thirty
per cent were walking with the aid of a cane,
25 per cent with crutches or a cane, and 5 per
cent were confined to wheelchairs. No patient
was bedridden. In 5 per cent of the series, the
present status was unknown.

All of the patients were asked to evaluate the
results of their surgery. They were requested to
be factual and frank in their answers. Twenty
per cent regarded their postoperative results as
excellent; 53M per cent felt that the results were
good; 13M per cent stated that the results were
fair; and 13/3 per cent reported poor results. This
evaluation was based on 15 hips in 14 patients;
2 were dead, 1 was mentally confused, and the
whereabouts of 3 was unknown.

Results were also evaluated by the author
based either on examination or interpretation of
answers to questions in the questionnaires. These
evaluations were: excellent— 10 per cent, good-
65 per cent, fair— 15 per cent, and poor— 10 per
cent.

Of the 21 hips operated upon, 6 patients had
no pain in the operated joint, 5 had mild pain, 5
moderate pain, 1 severe pain, and, in 4, the
evaluation of pain was not determined.

Patients were asked the question, “Is your hip
better, worse, or the same as before operation?”

Fig. 2. Moore prosthesis in place.

Eighteen stated it was better, 1 stated that it was
worse, and 1 stated that it was the same as before
surgery.

COMPLICATIONS

A number of complications have followed in-
sertion of femoral prostheses. These have in-
cluded dislocation of the prosthesis, fracture of
the prosthesis, fracture of either the acetabulum
or the femur, infection, phlebitis, rotation of
stem-type prostheses producing pain, and settl-
ing of prostheses due to erosion of underlying
supporting bone.

In the 23 hips operated upon here, dislocation
has occurred in 2 instances. One of these was
treated by closed reduction and a spica cast for
one month. The patient then became ambulatory
and no further dislocation occurred. Unfortu-
nately, he was killed in a fire five months later
so follow-up study was brief. In the second
patient with dislocation, closed reduction was
unsuccessful. Open reduction was, therefore,
carried out and a spica cast applied and main-
tained for one month. The prosthesis remained
reduced, but, as the patient was mentally con-
fused, she was confined to a wheelchair until her
death, which was caused by a cerebrovascular
accident three months after leaving the hospital.

No broken prostheses occurred in this series.
Fracture of the acetabulum also did not occur,
but the shaft of the femur broke three times dur-
ing surgery. An Eicher prosthesis was used in
2 of these instances, and a Moore vitallium pros-
thesis was used in the other. In each case, frac-
ture was not extensive enough to interfere with
secure seating of the prosthesis and uneventful
healing followed. Each of these patients is am-
bulatory at the present time.

SEPTEMBER 1958

371

No infection, phlebitis, or postoperative mor-
tality has occurred in any of the patients of this
series.

In one patient in whom a metal Judet prothesis
had been used, the device settled with gradual
erosion of the underlying bone of the neck of the
femur, allowing lateral protrusion of its stem.
Over a period of months, an annoying bursitis
occurred over the protruding stem, which finally
necessitated its removal. This was accomplished
by use of a circular saw. The saw was used in
a Luck motor, and about forty-five minutes of
actual cutting time was required to remove the
stem. Postoperatively, the bursitis was relieved,
and the patient remained ambulatory with the
use of 1 cane until his death from acute leukemia
four years after operation.

CONCLUSIONS

The femoral head replacement prosthesis is an
extremely useful orthopedic appliance. It is felt
that it should not be used routinely for fresh hip
fractures unless specifically indicated, as in men-
tally confused or extremely uncooperative pa-
tients in whom hip nailing would probably be
unsuccessful.

It is felt that the vitallium Moore prosthesis is
the best available at the present time (figure 2).
However, the vitallium Eicher, shaped much

like the Moore but with a longer neck and nar-
rower stem, should be useful when the femoral
neck is gone.

SUMMARY

During the past five years, 23 femoral head pros-
theses have been inserted at the Northwest
Clinic. A review of these cases has been pre-
sented. Six different types of femoral head pros-
theses were used. At the present time, the vitall-
ium Moore is the prosthesis of choice.

Complications of intracapsular hip fractures,
including nonunion and aseptic necrosis of the
femoral head, are the chief indications for in-
sertion of a femoral head prosthesis.

A candidate for this procedure should be
sufficiently disabled preoperatively to require
the use of a cane or crutch. This is particularly
important when the indication for insertion of
a prosthesis is an arthritic hip with an intact
femoral neck. Patients with rheumatoid arthritis
involving the hip joints frequently have pain and
limited motion after insertion of a femoral head
prosthesis.

REFERENCES

1. Gibson, A.: Posterior exposure of hip joint. J. Bone & Joint

Surg. 32-B: 183, 1950.

2. Moore, A. T.: The self-locking metal hip prosthesis. J. Bone

& Joint Surg. 39-A:811, 1957.

Intense pain in the lower extremities mav be caused by neoplasms of the
peripheral nervous system. Diagnosis is aided by thorough systemic examina-
tion, including careful palpation of the peripheral nerves.

Peripheral nerve tumors may be the site of local pain that radiates along
the course of the nerve. Pain produced by tumors is generally constant and is
not alleviated by rest, heat, or cold. Sensory or motor defects may not be
apparent if the tumor is benign. Bv palpation, tumors of peripheral nerves
are tender, round, smooth, and well demarcated. Such tumors are movable
from side to side hut are fixed in the long axis of the nerve. Comparison of
palpatory findings in the contralateral limb is helpful when small tumors are
suspected.

Treatment consists of surgical removal. Perineural fibroblastomas, the most
common solitary tumor found on peripheral nerves, push the nerve trunk to
one side or expand the nerve trunk about the tumor. The nerve does not enter
the mass hut is displaced laterally or completely surrounds the tumor so that
a good cleavage plane often is found and nerve function is not impaired. If
the tumor is thought to he malignant or sharp separation is not possible, resec-
tion should be done. Loss of nerve length can he corrected bv proper position-
ing of the extremity, mobilization of the proximal and distal nerve ends, and
rerouting of the nerve.

Sidney W. Gross, M.D., and Aaron Schwartz, M.D., Mount Sinai Hospital, New York City.
Neurology 7:711, 1957.

372

THE JOURNAL-LANCET

Eczema, Allergic Rhinitis, and Asthma
in Infancy and Childhood

ROBERT B. TUDOR, M.D.

Bismarck, North Dakota

The purpose of this paper is to emphasize
the importance of diagnosing and treating
allergic diseases early in life. Ten per cent of
the population, or about 17 million people, are
allergic. According to Prickman,1 there is no
sharp dividing line between allergic and non-
allergic individuals. The allergic reaction is a
matter of threshold, which is lowest in those
who are sensitive to common allergens. A per-
son whose ancestors have been allergic merely
inherits the predisposition or capacity to become
sensitized. Certain cells in the body become sen-
sitized by contact with a substance, for example,
ragweed antigen, and specific cellular antibodies
develop for ragweed antigen. With subsequent
contact between ragweed antigen and the cellu-
lar antibodies, the cell is injured, resulting in the
liberation of histamine from the injured cell.
Since living tissue contracts the instant antigen
contacts it,2 the reactions may take place where
the nerve endings are located. This may mean
that acetylcholine is also secreted as a result of
the reaction and induces muscle contractions
that cause sneezing, asthma, or gastrointestinal
upsets. The possibility that serotonin may be
one of the causes of asthma and other allergic
respiratory disturbances has recently been re-
ported/5 The concept that allergy is produced by
the splitting of proteins by enzymes has been
supported by Johnstone, Becker, and Osier.4 5
The shock organ or the site of the reaction is not
constant even in the same individual or even in
response to the same antigen.

The eczema of infancy may clear up and be
followed by asthma or allergic rhinitis. The typ-
ical sequence is:6 eczema in infancy due to
foods, especially to egg and cow’s milk; asthma
in childhood from dusts, especially animal dan-
ders; and, later, hay fever from pollen. Persons
with a family history of frequent severe allergic

Robert b. tudor is a member of the Quain and
Ramstad Clinic, Bismarck, North Dakota.

Tins paper was presented at the annual meeting
of the North Dakota State Medical Association,
Fargo, May 28, 1957.

disease tend to have clinical manifestations of
allergy early in life." Emotional stress may be
accompanied by vascular changes that are iden-
tical with those seen in immunologic allergy.
These vascular changes are thought to be caused
by the liberation of acetylcholine at vasomotor
nerve endings.

DIAGNOSIS

It is of extreme importance to diagnose allergic
manifestations as early as possible so that more
chronic allergies may be prevented. Clein8
showed that 39 per cent of 100 infants exhibited
their first allergic symptoms by the age of 1
month and 89 per cent by the age of 1 year.
Therefore, it is obvious that most allergies should
be diagnosed by the end of the first year. Mani-
festations of cow’s milk allergy are some of the
earliest allergies seen.1' Colic, vomiting, diarrhea,
nasal stuffiness, cough, wheezing, or eczema may
occur following exposure to cow’s milk during
the neonatal period.

After the clinical diagnosis is made, the physi-
cian should search for the cause by skin test-
ing.1"11 The number of allergens used in testing
is best determined according to the locale and
age of the patient. From the standpoint of safety,
the scratch test is the method of choice, espe-
cially in children. Immediate or delayed gen-
eral reactions to scratch tests are extremely rare
and, to my knowledge, have not resulted in a
single fatality. Children react to test substances
more readily and with weaker extracts than do
adults. Peshkin12 has emphasized several pit-
falls in the interpretation of the skin tests. The
size or intensity of the skin reaction to an aller-
gen does not determine its importance in the
etiology or does it indicate the degree of general
sensitivity that is present. Pollen asthma may
occur with negative cutaneous reactions to pol-
len but with typical seasonal incidence. A his-
tory will show that a patient can be sensitive to
a given substance despite the fact that the skin
reactions may be negative. Many positive aller-
gic skin test reactions eventually and spontane-
ously become permanently negative. The disap-

SEPTEMBER 1958

373

pearance of a positive skin reaction to a food
does not necessarily indicate clinical tolerance
to that food. Specific hyposensitization treat-
ment against the causal pollen during a period
of years may result in complete eradication of
the positive skin reaction to the exciting pollen.
This does not imply that the patient is cured of
pollenosis.

ALLERGENS IN INFANCY

This paper is based on my experience with 396
patients, 117 with allergic rhinitis, 172 with ec-
zema, and 107 with asthma. The most common
food allergens in my practice in the order of
number of positive skin tests are found in table
1. The most common pollens, inhalants, epider-
mals, molds, and insects are found in table 2. 13
House dust is a very complicated antigen con-
taining bacteria, molds, insect dust, animal dan-
der, and cottonseed. Allergies due to house dust
are usually worse in the fall and winter after
forced air heaters are turned on. The pollen sea-
sons for Bismarck are shown in figure 1.

Feather pillows and old mattresses are an im-
portant source of fungi. In a series of 380 cases,
molds caused clinical allergy in 111, or 29 per
cent.14

Other allergens, which probably are of more
significance than we realize, are the hydrocar-
bons, such as stove gas, auto exhausts, gasoline,
kerosene, perfume, Glass Wax, naphtha moth
balls, artificial coloring, Lysol, phenol, fresh
newsprint, rubber, detergents, and shoe polish
and the physical agents — cold, sunlight, and
heat. These may act as triggers to set off an at-
tack of clinical allergy.

TABLE 1

COMMON FOOD ALLERGENS

1.

Milk

11.

Salmon

2.

Spinach

12.

Pork

3.

Tomatoes

13.

Corn

4.

Walnuts

14.

White potatoes

5.

Oranges

15.

Peanuts

6.

Chocolate

16.

Carrots

7.

Egg white

17.

Peaches

8.

Bananas

18.

Beets

9.

Peas

19.

Wheat

10.

Apples

20.

Sweet potatoes

TABLE 2

COMMON INHALANTS

Inhalants and epidermals:

House dust, feathers, wool, animal dander, cotton-
seed, tobacco smoke.

Pollens:

Trees: Box elder, cottonwood, elm, oak.

Grasses: June, orchard, timothy.

Weeds: Ragweed, chenopod, amaranth, sage, plantain.
Molds: Hormodendrurn, Alternaria
Insects: Caddis Hies, May flies

The inhalants are usually carried by warm air,
and so the fallout is greatest on the windward
side of a city and least on the leeward side.15
Warm air rising over the city carries them up
into the clouds. The fallout is also greatest at
night and in early morning because at these
times there is a layer of cool air surrounding the
earth into which the warm air slowly flows.

March

April

May

June

July

Aug

Sept.

Oct.

Nov.

Dec.

WW

cVx'X

^^Tree

s

( Maple - Box Elder - Elm

- Cottonwood - Oak )

Pine

l . 7TTTX. .

i i j

Sage :

! — |

Chenopod Amaran

«... I 'a a .. A .. .. *.•>

th';;3$

Plantain

[Ragweed

$

Fig. 1. Pollen seasons, Bismarck, North Dakota, 1956-1957.
THE JOURNAL-LANCET

374

TABLE 3

ALLERGIC DERMATOSES

1. Atopic eczema

2. Atopic erythroderma

3. Seborrheic eczema

4. Nummular eczema

5. Contact eczema

6. Infectious eczema

7. Herpetic eczema

8. Eczema vaccinatum

9. Neurodermatitis
It). Urticaria

11. ID reactions

12. Erythema multiforme

13. Drug reactions

ECZEMA

Before making a clinical diagnosis of atopic ec-
zema, a differential diagnosis should be carefully
considered (table 3). The child with atopic ec-
zema may have pale, comparatively cool, clam-
my skin.10 The disease is attended by extreme
itching, and there is usually heat, redness, swell-
ing, vesiculation, oozing, and crusting. Blockage
of the sweat ducts may cause sweat retention.
This is manifested by small, deep seated vesicles
on the palms and along the sides of the fingers.
Atopic eczema may progress and become sebor-
rheic, but it is unusual for seborrheic eczema to
become atopic. In seborrheic eczema, potato
chip scaling occurs; the eruption is usually or-
ange colored and waxy; itching is less intense;
and scratching and lichenification are usually
absent. These lesions usually clear centrally.
Seborrheic lesions taper off abruptly, involve the
diaper area, and they do not cause depigmenta-
tion of the skin as the atopic eczemas do. If the
skin is examined closely, tesselation or checker-
boarding is often seen. It is important to make
an etiologic diagnosis as early as possible by skin
testing or food avoidance. If the eczema flares
during the pollen season or when there is an
increased amount of dust in the house, the child
should be desensitized against those inhalants.17
The diet and environment should be restricted.
Even when the skin tests are negative, it is wise
to avoid milk, wheat, eggs, oranges, chocolate,
fish, nuts, spinach, and tomatoes. Fuzzy toys,
plastic articles, and feathers should be kept away
from the child. If there is a wool carpet in the
room in which the child spends most of his time,
it is wise to immobilize the dust in this area by
spraying with Allergex. Watery solutions should
be used when the eruption is subacute or chron-
ic. Burow’s solution, Zephiran solution, saline
solution, or Aveeno may be used until the erup-
tion is dry. An ointment incorporating aluminum
acetate, such as Burow’s paste or Hydrosal, will
speed the drying of the lesions. Lassar’s plain
zinc paste is the most popular ointment for
chronic eczema. Into this paste coal tar, wood

tar, bituminous tar, petroleum tar, or ammoni-
ated mercury may be incorporated in 2 per cent
concentrations. Bituminous tar, Ichthyol, has
the action of coal tar without causing irritation
in subacute eruptions and is a good medication
to use initially. Coal tar may be used in 5 per
cent strength, as in Tarbonis, or in more spe-
cialized ointments like Kolpix A, which is high
in tar acids, and Kolpix D, which is high in
naphthalene. Four steroids are available in oint-
ments, creams, or lotions. They cause different
reactions on the skin, and eruptions which are
irritated by one may subside following the use
of another. These four steroids are hydrocorti-
sone, prednisolone, fludrocortisone (Florinef ace-
tate), and hydrocortisone ethamate hydrochlor-
ide (Magnacort). The quinolines, Sterosan and
Vioform, are antieczematous and antifungicidal.
They may be incorporated into a tar. In the
presence of secondary infection, it may be neces-
sary to use an antibiotic on the skin. It is wise
to use antibiotics that are not given in excess
internally, such as polymyxin B, bacitracin, or
neomycin. For severe itching and lesions which
cover much of the skin, the steroids should be
administered by mouth or by injection. There is
no reason why a sick or very irritable child
should be denied the relief that one of the ster-
oids will provide. I achieve my best results with
prednisolone or hydrocortisone in a dosage of
5 or 10 mg. every six hours until the desired ef-
fect has been secured. The antihistamines and
anticholinergics are used for their sedative and
antipruritic value. They have pronounced his-
tamine antagonism and some local anesthetic
value. The tranquilizers may supplement other
medication. It is sometimes necessary to use
ultraviolet radiation on the skin, and some chil-
dren are relieved if they are moved to a warm
climate.

ALLERGIC RHINITIS

Seasonal and perennial allergic rhinitis present
about the same problems, and so I will consider
them together. The diagnosis is easy to make if
thought is given to these conditions and if the
nose and throat of each child are examined. The
nasal mucosa and throat mucosa are usually pale,
though they may be reddened if the child has
a secondary bacterial infection. A smear taken
from the nose or posterior pharynx and stained
with Hansel’s stain will show clumps of eosino-
phils.18 Wright’s stain will not readily bring out
the eosinophils. Blood eosinophilia in excess of
4 per cent may be present. Roentgenograms
usually show opaque sinuses. These children
may or may not sneeze a great deal. Their noses

SEPTEMBER 1958

375

are always stuffy, and their history reveals that
they continually breathe through their mouths.
They should be skin tested and desensitized with
the pollens, molds, dusts, and epidermals to
which they are sensitive.19 The diet and envi-
ronment should be restricted. Nose drops are
of no benefit. Steroids given orally may help to
bridge the period of skin testing and may bring
relief during periods of more acute allergy. Irra-
diation of the nasopharynx may be necessary in
order to obtain the optimum benefit from the
allergic treatment. Untreated allergic rhinitis
may be associated with obstructive hearing loss.

ASTHMA

Asthma should be diagnosed as early as possi-
ble in order to prevent the development of
chronic lung pathology.20,21 In making the clin-
ical diagnosis, it is wise to consider that all asth-
matic patients wheeze but that not all those who
wheeze have asthma. Conditions in the lung,
bronchi, and mediastinum, such as childhood
bronchiolitis and pancreatic fibrosis, should be
ruled out. All asthmatic children have allergic
rhinitis. They should all be skin tested and de-
sensitized. The diet and environment should be
restricted. In the treatment of the acute case,
the following are of importance: an allergen-free
room, rest, control of cough, liquefaction of spu-
tum, prevention of anoxemia, and prevention of
complications.22 The chemical fogs, Alevaire and
Tergemist, are of great help in treatment of the
acute asthmatic attack. Prophylactic penicillin
may reduce the number of asthmatic attacks.
Potassium iodide in either saturated solution or
in tablets, such as Quadrinal, may be given
daily, preferably at bedtime. I usually give 10
drops of the saturated iodide solution or I2 of
a Quadrinal tablet daily. The cholinergic block-
ing agents, which decrease bronchial spasm and
mucous secretion, do not usually help. The sym-
pathomimetic drugs, Adrenalin, ephedrine, or
Isuprel, may be used in treatment of the acute
attack as well as in the prevention of flare-ups.
The xanthine alkaloids stimulate the bronchial
muscle directly. They may be given by mouth
or rectally. The most popular antiasthmatic
medications contain ephedrine, aminophylline,
and phenobarbital or an antihistamine. They
may be given to treat an acute attack, or they
may be given daily to help in prevention. The

steroids are of great value in treatment of acute
asthma. The quicker the asthmatic wheezing is
controlled, the less severe the asthmatic attack,
so that I don’t hesitate to start a patient with
severe asthma with 5 or 10 mg. or predniso-
lone or hydrocortisone every six hours until the
wheezing is controlled. The antihistamines are
of no value in the treatment of asthma. Nebu-
lizers, which usually nebulize Adrenalin or Isu-
prel, are of some value, but I have had no great
success with them except in the occasional case.
Irradiation of the nasopharynx may help. Inter-
mittent positive pressure breathing with Alevaire
and Isuprel is mentioned for the sake of com-
pleteness, but I have had no experience with
these agents for this purpose. A child with asth-
ma in whom there is a great emotional compo-
nent is also said to benefit if he is removed from
the home.

Dr. Glaser23 has shown that the development
of major allergic diseases in potentially allergic
infants is greatly decreased by avoidance of
cow’s milk. In a study be made with 336 chil-
dren, cow’s milk was withheld from birth in 96,
and, in this group, a major allergy developed in
only 14.6 per cent in six years. In a control group
of 175 children who were nonrelated to the ex-
perimental group, a major allergy developed in
52 per cent in six years. In a control group of
65 children who were siblings of the experimen-
tal group, a major allergy developed in 64.6
per cent in six years. It has been my practice to
withhold cow’s milk from birth in infants who
are born into families with frequent severe aller-
gies. Babies take Mull-Soy, meat base, or Nu-
tramigen easily. After one year’s avoidance,
cow’s milk can be introduced into the diet with-
out difficulty.

SUMMARY

The importance of early clinical and etiologic
diagnosis of eczema, allergic rhinitis, and asth-
ma in infancy and childhood has been empha-
sized. Fewer severe allergies occur in the older
child if allergic manifestations are treated vig-
orously in infancy.

Tlie preparation of this paper would have been im-
possible without the cooperation of my associates at the
Quain and Ramstad Clinic and Dr. Norman Clein of
Seattle, Washington.

REFERENCES

1. Prickman, L. E.: General principles of allergy and hyper-

sensitivity. Proc. Staff Meet. Mayo Clin. 24:429, 1949.

2. Pauling, L., and Campbell, D.: Unpublished observations
made at the annual meeting of the American Academy of
Allergy, Los Angeles, 1957.

3. Waalkes, T. P., Weissbach, H., and Undenfriend, S.: Un-

published observations made at the National Heart Institute.
Bethesda, Maryland, May, 1957.

4. Johnstone. D. E., and Becker. E. L.: Presented at the an-
nual meeting of the American Academy of Allergv, February
4, 1957.

5. Osler. G. F.: Presented at the annual meeting of the Ameri-

376

THE JOURNAL-LANCET

can Association of Immunologists, Chicago, April 18, 1957.

6. Rackemann, F. M., and Edwards, M. C.: Asthma in chil-
dren; follow-up study of 688 patients after interval of 20
years. New England J. Med. 246:815, 1952; 246:858, 1952.

7. Crede, R. H., Carman, C. T., Whaley, R. D., and Schu-
macher, I. C.: Dissimilar allergic disease in identical twins.
California Med. 78:25, 1953.

8. Clein, N. W.: Cow’s milk allergy in infants. Pediat. Clin.

North America 1:949, 1954.

9. Tudor, R. B.: Gastrointestinal allergy to cow’s milk in the

neonatal period. Journal-Lancet 76:245, 1956.

10. Ratner, B., Crawford, L. V., and Flynn, J. CL: Allergy

in the infant and preschool child. A.M.A. Am. J. Dis. Child.
91:593, 1956.

11. Glaser, J.: Allergy in Childhood. Springfield, Illinois:

Charles C Thomas, 1956.

12. Peshkin, M. M.: Pitfalls of skin tests in allergy. J. A.M.A.

157:820, 1955.

13. Feinberg, A. R., Feinberg, S. M., and Benaim-Pinto, C.:
Asthma and rhinitis from insect allergens. J. Allergy 27:437,
1956.

14. Eisenstaot, W. S.: Incidence and significance of molds in

allergic respiratory symptoms. Journal-Lancet 68:217, 1948.

15. Heise, H. A., and Heise, E. R.: Effect of a city on the fall-
out of pollens and molds. J. A.M.A. 163:803, 1957.

16. Lobitz, W. C., Jr., and Dobson, II. L.: Physical and physio-
logical clues for diagnosing eczema. J. A.M.A. 161:1226, 1956.

17. Hill, L. W.: Eczema in infancy and childhood. New Eng-
land J. Med. 242:286, 1950.

18. Hansel, F. K.: Allergy of upper and lower respiratory tracts
in children. Ann. Otol. Rhin. & Laryng. 49:579, 1940.

19. Henderson, L. L., and others: Diagnosis and management

of hay fever. Proc. Staff Meet. Mayo Clin. 28:497, 1953.

20. Prickman, L. E.: Asthma — objectives of treatment and their
attainment. J. A.M.A. 161:937, 1956.

21. Bernstein, C., and Klotz, S. D.: Treatment of asthma.

J. A.M.A. 157:811, 1955.

22. McLean, J. A., Coogan, M. A., and Sheldon, J. M.: Sub-
cutaneous emphysema as a complication of bronchial asthma.
Univ. Michigan M. Bull. 22:295, 1956.

23. Glaser, J.: Prophylaxis of allergic disease with special ref-

erence to newborn infant. New York J. Med. 55:2599, 1955.

Surgery is not necessary for babies with sternocleidomastoid tumors that do
not cause progressive deformity.

The swelling in the sternocleidomastoid muscle usually appears ten to four-
teen days after birth. The hard, fusiform, immobile, and nontender mass in-
creases for two to four weeks, nearing the size of a large almond. Most growths
disappear by the fifth to the eighth month and cause no deformity.

Of 1,283 newborn infants, 23 had sternocleidomastoid tumors, an incidence
of 1 in 56. None of the 20 children who were observed for as long as four
years had deformities.

Felix G. Line, M.D., and Mary Lee Line, M.D., Knoxville, Tennessee. 1. Tennessee M.A.
51:133, 1958.

Any abdominal mass in a newborn infant should receive prompt surgical ex-
ploration. Preliminary studies include abdominal roentgenograms, intravenous
urograms, urinalysis, complete blood count, and nonprotein nitrogen determi-
nation.

Of 32 infants in whom an abdominal mass was noted on the first day of
life, 30 were operated upon, with a mortality of 10 per cent. A malignant
tumor was found in 4 patients.

One-half the masses were in the kidneys. One-third of these were located
so far anteriorly that renal origin was suspected only after orographic study.
In 13 infants with unilateral hypoplastic multicvstic kidneys, the normal kidney
has remained so for periods up to twenty years.

Masses in 6 infants were in the digestive system and included liver cyst,
choledochal cyst, distended gallbladder, duplication of the ileum, mesenteric
cyst, and ileal volvulus in 1 patient each.

Other benign masses consisted of 2 ovarian evsts, 3 hvdrometrocoljios, and
1 teratoma. Wilms’s tumor, neuroblastoma, leiomyosarcoma of the colon, and
primary hepatoma made up the 4 malignant neoplasms.

The Wilms’s tumor was discovered incidentally during the first day of life
as a right flank mass in an infant with erythroblastosis. After exchange trans-
fusion had corrected the hematologic condition, a right nephrectomy was suc-
cessfully performed, and the child is still well at the age of 4 years.

Luther A. Longino, M.D., and Lester W. Martin, M.D., Harvard Medical School and Chil-
dren’s Hospital, Boston. Pediatrics 21:596, 1958.

SEPTEMBER 1958

377

Use of the Multi-Interval Blood Glucose
Method in a Diabetic Children’s Camp

E. A. HAUNZ, M.D., and JERRY WEISBERG, M.Sc.
Grand Forks, North Dakota

The multi-interval blood glucose method,
utilizing the Clinitron, has been described
in a previous paper,1 which includes a descrip-
tion of the machine capable of automatically
processing blood samples for the estimation of
blood glucose. The purpose of this report is to
present further objective evidence of the clin-
ical usefulness of the method in the manage-
ment of juvenile diabetes in a summer camp
with verv limited laboratory facilities. This pro-
cedure has been successfully utilized by us for
the past three years at Camp Sioux for diabetic
children, which is sponsored annually by the
North Dakota Diabetes Association, Inc., at
Turtle River State Park, Arvilla, North Dakota.

Each of 22 campers was carefully checked
daily at bedtime by the camp physician. All
patients whose urine tests had shown excessive
glycosuria, with or without acetonuria, and all
those experiencing moderate to severe hypogly-
cemic reactions during the day’s activities were
required to have blood glucose determinations
to aid in proper adjustment of insulin dosage.
The procedure for collecting blood and process-
ing blood glucose determinations was as fol-
lows:

Blood specimens were obtained by venipunc-
ture and added immediately to tubes contain-
ing potassium oxalate and sodium fluoride. A
preliminary screening of the specimens was done
to see if their glucose content exceeded the 130-
mg. per cent level. This was done by adding 0.1
ee. of the blood specimen to 5.0 cc. of distilled
water in a Clinitron reaction tube. The tubes
were then processed by the Clinitron, utilizing
ferricyanide tablet 3A. The color of the reaction
tube was noted after completion of the process,
and a blue reaction indicated a glucose concen-
tration below 130-mg. per cent. A colorless re-

e. a. haunz is associate professor of clinical medi-
cine at the University of North Dakota School of
Medicine, jerry weisberg is research assistant in
the Department of Biochemistry at the University
of North Dakota School of Medicine.

action indicated a glucose concentration greater
than 130-mg. per cent.

Blood specimens with glucose concentrations
in excess of 130-mg. per cent were then further
analyzed by the multi-interval blood glucose
method.

One cubic centimeter of the blood specimen
was diluted with 9.0 cc. of distilled water in a
test tube and mixed. A series of 5 reaction tubes
containing 4.0 cc. of distilled water was pre-
pared. The following quantities of blood-water
mixture were added to the tubes:

0.9 cc. of the blood-water mixture was added
to tube 1.

0.8 cc. of the blood-water mixture was added
to tube 2.

0.7 cc. of the blood-water mixture was added
to tube 3.

0.6 cc. of the blood-water mixture was added
to tube 4.

0.5 cc. of the blood-water mixture was added
to tube 5.

The tubes were processed in the Clinitron,
utilizing ferricyanide reagent tablets 3A. The
first tube in the series to show a blue reaction
was considered the end point. Tims, a blue re-
action in tube No. 1 represented a blood glucose
level of less than 144-mg. per cent but more than
130-mg. per cent. A blue reaction in tube No. 2
represented a blood glucose level of less than
162-mg. per cent but more than 144-mg. per
cent. A blue reaction in tube No. 3 represented
a blood glucose level of less than 186-mg. per
cent but more than 162-mg. per cent. A blue
reaction in tube No. 4 represented a blood glu-
cose level of less than 217-mg. per cent but more
than 186-mg. per cent. A blue reaction in tube
No. 5 represented a blood glucose level of less
than 260-mg. per cent but more than 217-mg. per
cent.

In 9 instances, a colorless reaction occurred in
all 5 reaction tubes, indicating a blood glucose
concentration greater than 260-mg. per cent. In
these cases, reaction tubes No’s. 6 and 7 were
prepared containing 4.0 cc. of distilled water
and 0.4 cc. of the blood-water mixture in tube
No. 6 and 0.3 cc. of the blood-water mixture in

378

THE JOURNAL-LANCET

TABLE 1

COMPARISON OF RESULTS OBTAINED FROM BLOOD SPECIMENS ANALYZED FOR GLUCOSE CONTENT BY THE
SOMOGYI-NELSON TECHNIC AND THE CLINITRON MULTI-INTERVAL BLOOD GLUCOSE METHOD USING TABLET 3A

Case

Concen-

T ube 1

T ube 2

Tube 3

T ube 4

Tube 5

Tube 6

Tube 7

Number

tration

130 to 144-

144 to 162-

162 to 186-

186 to 217-

217 to 260-

260 to 325-

325 to 433-

mg. %

mg. %

mg. %

mg. %

mg. %

mg. %

mg. %

1

218

c

c

c

B

B

2

209

c

c

c

B

B

5

230

c

c

c

C

B

8

187

c

c

B

B

B

19

130

B

B

B

B

B

4

184

C

C

B

B

B

8

290

C

C

C

C

C

C

B

9

256

C

C

C

C

B

1

269

C

C

C

C

C

B

B

9

264

C

C

C

C

C

B

B

14

240

c

c

C

C

B

16

250

c

c

C

C

C

B

B

6

183

c

c

B

B

B

7

128

B

B

B

B

B

8

230

c

C

c

C

B

20

280

c

C

c

C

C

B

B

22

141

B

B

B

B

B

23

290

c

C

C

C

C

B

B

1

275

c

C

C

C

C

B

B

4

235

c

C

C

C

B

5

180

c

C

B

B

B

8

240

c

C

C

C

B

16

262

c

c

C

C

C

B

B

1

214

c

c

C

B

B

6

242

c

c

C

C

B

8

257

c

c

C

C

B

12

184

c

c

B

B

B

20

268

c

c

C

C

C

B

B

Concentration = Actual blood glucose concentration in mg. % as determined by the Somogyi-Nelson technic.
Tube 1 = A blue reaction (B) in Tube 1 represents a glucose level within the increment of 130 to 144-mg. %.

Tube 2 = A blue reaction ( B ) in Tube 2 represents a glucose level within the increment of 144 to 162-mg. %

Tube 3 = A blue reaction ( B ) in Tube 3 represents a glucose level within the increment of 162 to 186-mg. %.

Tube 4 — A blue reaction (B) in Tube 4 represents a glucose level within the increment of 186 to 217-mg.%.

Tube 5 = A blue reaction (B) in Tube 5 represents a glucose level within the increment of 217 to 260-mg. %.

Tube 6 = A blue reaction (B) in Tube 6 represents a glucose level within the increment of 260 to 325-mg. %.

Tube 7 = A blue reaction (B) in Tube 7 represents a glucose level within the increment of 32.5 to 433-mg. %.

tube No. 7. A blue reaction in tube No. 6 rep-
resented a blood glucose concentration of less
than 325-mg. per cent but more than 260-mg.
per cent. Finally, a blue reaction in tube No. 7
represented a blood glucose concentration of
less than 433-mg. per cent but more than 325-
mg. per cent.

Table 1 illustrates a comparison of results
of those blood specimens with concentrations
above 130-mg. per cent, analyzed by the con-
ventional Somogyi-Nelson technic and the multi-
interval blood glucose method, respectively.
Blood specimens with a glucose concentration
less than 130-mg. per cent were analyzed as fol-
lows:

A series of 5 reaction tubes containing 3.0 cc.
of water was prepared. In a separate test tube,
1.0 cc. of blood was diluted with 9.0 cc. of water.

1.2 cc. of the blood-water mixture was added
to tube 1.

1.4 cc. of the blood-water mixture was added
to tube 2.

1.8 cc. of the blood-water mixture was added
to tube 3.

2.2 cc. of the blood-water mixture was added
to tube 4.

3.0 cc. of the blood-water mixture was added
to tube 5.

Into each reaction tube, 1 extra tablet No. 1
and 1 extra tablet No. 2 were manually added.
This provided the necessary additional precipi-
tating reagents needed for the increase in the
amount of blood used in these determinations.
The reaction tubes were then placed in the
Clinitron and processed with reagent tablet 3A.
The first tube in the series showing a colorless
reaction following a series of blue reactions was

SEPTEMBER 1958

379

TABLE 2

COMPARISON OF
SOMOGYI-NELSON

RESULTS

TECHNIC

ORTAINED FROM BLl
AND THE CLINITRON

OOD SPECIMENS
MULTI-INTERVAL

ANALYZED FOR GLUCOSE
BLOOD GLUCOSE METHOD

CONTENT BY THE
USING TABLET 3A

Case

Concen-

Tube 1

Tube 2

Tube 3

Tube 4

Tube 5

Number

tration

108 to 130-
mg- %

93 to 108-
mg. %

72 to 93-
mg- %

59 to 72-
mg. %

43 to 59-
mg. %

5

50

B

B

B

B

C

15

70

B

B

C

C

C

22

94

B

C

C

C

c

4

52

B

B

B

B

c

21

48

B

B

B

B

c

10

62

B

B

B

C

c

8

82

B

B

C

C

c

6

62

B

B

B

C

c

24

51

B

B

B

B

c

1

60

B

B

B

C

c

17

48

B

B

B

B

c

26

64

B

B

B

C

c

15

69

B

B

B

C

c

23

75

B

B

C

C

c

24

43

B

B

B

B

B

26

99

B

C

C

C

c

6

79

B

B

C

C

c

21

80

B

B

c

c

c

14

48

B

B

B

B

c

15

84

B

B

C

C

c

Concentration = Actual blood glucose concentration in mg. % as determined by the Somogyi-Nelson technic,
lube 1 = A colorless reaction (C) in Tube 1 represents a glucose level within the increment of 108 to 130-mg. %
Tube 2 = A colorless reaction (C) in Tube 2 represents a glucose level within the increment of 93 to 108-mg. %.

Tube 3 = A colorless reaction (C) in Tube 3 represents a glucose level within the increment of 72 to 93-mg. %.

Tube 4 r: A colorless reaction (C) in Tube 4 represents a glucose level within the increment of 59 to 72-mg. %.

Tube 5 = A colorless reaction (C) in Tube 5 represents a glucose level within the increment of 43 to 59-mg. %.

considered the end point. A colorless reaction in
tube No. 1 represented a blood glucose level
greater than 108-mg. per cent but less than 130-
mg. per cent. A colorless reaction in tube No. 2
represented a level greater than 93-mg. per cent
but less than 108-mg. per cent. A colorless re-
action in tube No. 3 represented a level greater
than 72-mg. per cent but less than 93-mg. per
cent. A colorless reaction in tube No. 4 repre-
sented a level greater than 59-mg. per cent but
less than 72-mg. per cent. Last, a colorless reac-
tion in tube No. 5 represented a level greater than
43-mg. per cent but less than 59-mg. per cent.

Table 2 illustrates a comparison of results of
those blood specimens below 130-mg. per cent
analyzed by the conventional Somogyi-Nelson
technic and the multi-interval blood glucose
method, respectively. The Somogyi-Nelson pro-
cedure was used to obtain further confirmatory
evidence to indicate that the rapid multi-interval
blood glucose method is accurate and reliable
within limitations defined in our previous paper.

COMMENT

For practical clinical purposes, knowledge that
the actual blood sugar value falls within the
proposed intervals is quite satisfactory for man-
agement of the diabetic patient, including the
complications of acidosis and coma. As reported

THE JOURNAL-LANCET

previously,* 1 when blood is processed for levels
below 130-mg. per cent, the results are reported
in smaller intervals because it is obviously de-
sirable to obtain more specific results for lower
blood glucose levels. It should be emphasized
that only ten minutes was required to process all
10 of these patients’ specimens. It required about
ten minutes to process each set of the remaining
blood specimens by the multi-interval method.

SUMMARY

The multi-interval blood glucose method was
used in a summer camp comprised of 22 diabetic
children. Each blood specimen was initially
“screened” to determine if the actual value was
above or below 130-mg. per cent. The 29 speci-
mens having values above 130-mg. per cent were
processed by both the multi-interval Clinitron
method and the Somogyi-Nelson procedure.
Comparisons of the data presented reaffirm the
assertion that the multi-interval blood glucose
method is speedy, accurate, and reliable within
the limitations specified in the preceding paper.

The generous supply of Clinitron Reagent tablets sup-
plied bv Eli Lilly & Co., Indianapolis, Indiana, made this
investigation possible.

REFERENCE

1. Haunz, E. A., and Weisberg, J.: A multi-interval blood glu-
cose method utilizing the Clinitron. Diabetes 5:297, 1956.

380

Transactions of the North Dakota
State Medical Association

Seventy-First Annual Meeting
Minot, North Dakota, May 3, 4, 5, and 6, 1958

OFFICERS

President R. W. RODGERS, Dickinson

President-Elect O. A. SEDLAK, Fargo

First Vice-President J. C. FAWCETT, Devils Lake

Second Vice-President C. M. LUND, Williston

Speaker of the House G. A. DODDS, Fargo

Vice-Speaker of the House . . R. E. LEIGH, Grand Forks

Secretary . E. H. BOERTH, Bismarck

Treasurer E. J. LARSON, Jamestown

Delegate to the A.M.A. W. A. WRIGHT, Williston

Alternate Delegate to the A.M.A. T. E. PEDERSON, Jamestown

COUNCILLORS

Terms expiring 1958

G. W. TOOMEY, Devils Lake

R. D. NIERLING, Jamestown

A. R. GILSDORF, Dickinson

J. D. CRAVEN, Williston
Terms expiring 1959

V. G. BORLAND, Fargo

N. A. YOUNGS, Grand Forks

C. H. PETERS, Bismarck

Terms expiring 1960

D. J. HALLIDAY, Kenmare

G. CHRISTIANSON, Valley City

K. G. VANDERGON, Portland
Councillor at large

R. H. WALDSCHMIDT Bismarck

Council: Officers; Executive Committee

A. R. GILSDORF, Chairman
R. D. NIERLING, Vice-Chairman

C. H. PETERS, Secretary

BOARD OF MEDICAL EXAMINERS

Terms expiring 1958

C. A. ARNESON Bismarck

W. E. G. LANCASTER Fargo

V. J. FISCHER Minot

Terms expiring 1959

JOSEPH SORENESS . Jamestown

O. W. JOHNSON Rugby

H. L. REICHERT Dickinson

Terms expiring 1960

C. J. GLASPEL Grafton

R. O. GOEHL Grand Forks

W. A. WRIGHT Williston

HOUSE OF DELEGATES

FIRST DISTRICT

ARTHUR C. BURT

FRANK M. MELTON

W. L. MACAULAY

F. A. DE CESARE
JOHN S. GILLAM

E. J. BEITHON

D. G. JAEHNING, alternate

L. E. WOLD, alternate .

J. F. HOUGHTON, alternate
J. F. SCHNEIDER, alternate

B. F. AMIDON, alternate

HENRY A. NORUM, alternate . .

SECOND DISTRICT

WILLIAM FOX

R. M. FAWCETT
D. W. PALMER, alternate .

J. H. MAHONEY, alternate

THIRD DISTRICT

F. A. HILL Grand Forks

ROBERT PAINTER Grand Forks

W. C. DAILEY Grand Forks

G. L. COUNTRYMAN Grafton

R. E. MAHOWALD, alternate Grand Forks

W. P. TEEVENS, alternate Grafton

WELLDE FREY, alternate Drayton

ROBERT DE LANO, alternate Northwood

FOURTH DISTRICT

FRED ERENFELD Minot

V. J. FISCHER Minot

A. R. SORENSON Minot

F. D. NAEGELI Minot

A. F. HAMMARGREN Harvey

O. S. UTHUS, alternate Minot

B. HORDINSKY, alternate ...... Drake

W. B. HUNTLEY, alternate Minot

J. L. DEVINE, Jr., alternate Minot

FIFTH DISTRICT

G. CHRISTIANSON Valley City

C. J. KLEIN, alternate Valley City

SIXTH DISTRICT

R. W. HENDERSON Bismarck

MILTON NUGENT Bismarck

R. B. TUDOR Bismarck

CARL BAUMGARTNER Bismarck

EDMUND VINJE Hazen

SEVENTH DISTRICT

T. E. PEDERSON Jamestown

JOHN VAN DER LINDE Jamestown

R. O. SAXVIK, alternate Jamestown

JOHN N. ELSWORTH, alternate Jamestown

EIGHTH DISTRICT

A. K. JOHNSON Williston

DEAN STRINDEN, alternate Williston

NINTH DISTRICT

ROBERT GILLILAND Dickinson

KEITH FOSTER Dickinson

WALT HANEWALD, alternate Richardton

JULIAN TOSKY, alternate . Hebron

TENTH DISTRICT

R. W. MC LEAN Hillsboro

MERVIN ROSENBERG, alternate Northwood

COMMITTEES: HOUSE OF DELEGATES
Seventy-First Annual Meeting
STANDING COMMITTEES

Committee on Medical Education:

H. M. BERG, Chairman Bismarck

T. E. PEDERSON Jamestown

T. H. HARWOOD . Grand Forks

L. H. KERMOTT, Jr. Minot

J. H. MAHONEY Devils Lake

F. D. NAEGELI Minot

ROBERT PAINTER Grand Forks

NORMAN ORDAHL Dickinson

WILLIAM BUCKINGHAM Elgin

L. E. WOLD Fargo

C. V. BATEMAN Wahpeton

Committee on Necrology and Medical History:

E. H. BOERTH, Chairman ....... Bismarck

A. R. SORENSON Minot

H. E. FRENCH Grand Forks

R. E. LEIGH ... Grand Forks

WILLIAM LONG Fargo

P. G. ARZT Jamestown

D. J. HALLIDAY Kenmare

Committee on Legislation:

O. W. JOHNSON, Chairman Rugby

PAUL JOHNSON, Vice-Chairman Bismarck

H. L. REICHERT ........ Dickinson

Second District
Seventh District
Ninth District
Eighth District

First District
Third District .
Sixth District

Fourth District
Fifth District .
Tenth District .

Fargo

Fargo

F argo

F argo

. F argo
Wahpeton
Wahpeton

Fargo

. F argo

F argo

F argo
Fargo

Rugby
Devils Lake
Cando
Devils Lake

SEPTEMBER 1958

381

J. N. ELS WORTH Jamestown

C. A. ARNESON ......... Bismarck

L. F. PINE Devils Lake

ROBERT MC LEAN Hillsboro

DAVID JAEHNING Wahpeton

PERRY O. TRIGGS Fargo

R. O. GOEHL Grand Forks

C. M. LUND Williston

J. L. DEVINE, Jr. Minot

RUDOLPH FROESCHLE Hazen

Committee on Public Relations:

JOHN CARTWRIGHT, Chairman Bismarck

R. O. GOEHL Grand Forks

KEITH VANDERC.ON Portland

H. L. REICHERT ....... Dickinson

C. M. LUND Williston

MARTIN HOCHHAUSER Garrison

J. N. ELSWORTH Jamestown

L. F. PINE ........ Devils Lake

LESTER B. SHOOK Fargo

ROBERT KLING Bismarck

Committee on Official Publication:

E. H. BOERTH, Chairman Bismarck

P. L. BLUMENTHAL Mandan

JOSEPH CLEARY Bismarck

Committee on Public Health:

PERCY OWENS, Chairman Bismarck

C. O. MC PHA1L Crosbv

A. F. HAMMARGREN Harvey

G. L. LOEB San Haven

R. F. GILLILAND Dickinson

JOHN MOORE Grand Forks

W. L. MACAULAY Fargo

P. L. BLUMENTHAL Mandan

RICHARD RAASCH Dickinson

R. O. SAXVIK Jamestown

GALE RICHARDSON Minot

Committee on Medical Economics:

TED KELLER, Chairman Rugby

V. J. FISCHER Minot

E. J. LARSON Jamestown

C. H. PETERS Bismarck

V. G. BORLAND Fargo

C. B. PORTER Grand Forks

E. J. BEITHON Wahpeton

GALE RICHARDSON Minot

KEITH FOSTER Dickinson

W. A. WRIGHT Williston

CHARLES HEILMAN Fargo

F. E. ANDERSON Underwood

J. H. MAHONEY Devils Lake

Committee on Rural Health:

M. S. JACOBSON, Chairman Elgin

K. G. VANDERGON Portland

CLARENCE MARTIN Kensal

HERBERT WILSON New Town

ROBERT DE LANO Northwood

DOLSON PALMER Cando

R. E. HANKINS Mott

Committee on Scientific Program:

Appointment expiring 1958

F. D. NAEGELI Minot

JOHN GILLAM Fargo

Appointment expiring 1959

F. A. HILL Grand Forks

P. R. GREGWARE Bismarck

Appointment expiring 1960

K. G. FOSTER Dickinson

J. V. MILES, Jr Jamestown

SPECIAL COMMITTEES

Committee on Cancer:

C. M. LUND, Chairman Williston

G. W. HUNTER Fargo

E. J. LARSON Jamestown

O. W. JOHNSON Rugby

T. H. HARWOOD Grand Forks

GALE RICHARDSON Minot

ROGER BERG Bismarck

NORMAN B. ORDAHL Dickinson

MARSHALL LANDA Fargo

R. M. FAWCETT Devils Lake

Committee on Veterans Medical Service :

A. C. FORTNEY, Chairman Fargo

AMOS GILSDORF Dickinson

R. B. RADI, Bismarck

H. A. NORUM Fargo

RALPH MAHOWALD Grand Forks

Committee on Prepayment Medical Care:

C. H. PETEP", Chairman Bismarck

T. E. PEDER ION Jamestown

V. J. FISCHEI Minot

FRANK DE CESARE Fargo

W. A. WRIGHT Williston

GEORGE HART Minot

CHARLES PORTER Grand Forks

WILLIAM T. POWERS Grand Forks

L. T. LONGMIRE Devils Lake

JACK SPIER Fargo

K. G. FOSTER Dickinson

LESTER B. SHOOK Fargo

O. V. LINDELOW Bismarck

Committee on Nursing Education:

C. R. MONTZ, Chairman Bismarck

LLOYD RALSTON Grand Forks

R. O. SAXVIK Jamestown

HANS GULOIEN Dickinson

E. P. BRYANT Devils Lake

C. B. DARNER Fargo

R. S. LARSON Velva

Committee on Maternal and Child Welfare:

R. E. LUCY, Chairman Jamestown

J. H. MOORE Grand Forks

L. G. PRAY Fargo

JOHN GILLAM Fargo

CARL BAUMGARTNER Bismarck

E. P. BRYANT Devils Lake

BLAINE AMIDON Fargo

JOHN KELLER Williston

R. T. GAMMELL Kenmare

Committee on Crippled Children:

PAUL JOHNSON, Chairman Bismarck

C. W. HOGAN Jamestown

A. E. CULMER, Jr Grand Forks

D. T. LINDSAY Fargo

B. A. MAZUR Fargo

L. B. SILVERMAN Grand Forks

J. C. SWANSON Fargo

F. L. BEHLING Fargo

J. J. MCLEOD Grand Forks

R. D. NIERLING Jamestown

O. V. LINDELOW Bismarck

GLADYS MARTIN Dickinson

GORDON E. ELLIS Williston

Committee on Mental Health:

JOHN FREEMAN, Chairman Jamestown

LEE CKRISTOFERSON Fargo

J. T. CARTWRIGHT Bismarck

M. J. GEIB Fargo

G. D. ICENOGLE Bismarck

GEORGE VIGELAND Rugby

H. C. WALKER, Jr Williston

LORMAN L. HOOPES Minot

P. R. BERGER Grand Forks

Committee on Diabetes:

E. A. HAUNZ, Chairman Grand Forks

A. K. JOHNSON Williston

R. M. FAWCETT Devils Lake

P. ROY GREGWARE Bismarck

MARTIN HOCHHAUSER Garrison

DONALD BARNARD Fargo

W. H. WALL Wahpeton

K. G. FOSTER Dickinson

Committee on Geriatrics and Rehabilitation:

T. H. HARWOOD, Chairman Grand Forks

R. O. SAXVIK Jamestown

PAUL JOHNSON Bismarck

M. W. GARRISON Minot

LEE CHRISTOFERSON Fargo

WILLIAM C. NELSON Grand Forks

H. C. WALKER, Jn. Williston

Committee on Foreign Trained Physicians:

C. J. GLASPEL, Chairman Grafton

W. E. G. LANCASTER Fargo

TOSEPII SORKNESS Jamestown

O. W. JOHNSON Rugby

W. A. WRIGHT Williston

Committee on Emergency Medical Service:

ROBERT NUESSLE, Chairman Bismarck

J. L. DEVINE, JR Minot

ROBERT GILLILAND Dickinson

382

THE JOURNAL-LANCET

J. D. LE MAR Fargo

B. J. CLAYBURGH Grand Forks

M. R. GILCHRIST Rolla

JAMES V. MILES, Jh. Jamestown

A. C. FORTNEY Fargo

JAMES K. O’TOOLE Park River

R. W. HENDERSON Bismarck

W. B. HUNTLEY Minot

Committee on American Medical Education Foundation:

W. E. G. LANCASTER, Chairman Fargo

K. G. VANDERGON Portland

D. J. HALLIDAY Kenmare

T. H. HARWOOD Grand Forks

RALPH DUKART Dickinson

R. H. WALDSCHMIDT Bismarck

R. D. NIERLING Jamestown

JOSEPH CRAVEN Williston

G. H. HILTS Cando

G. L. COUNTRYMAN Grafton

Committee on Constitution and By-Laws:

R. B. RADL, Chairman Bismarck

G. A. DODDS Fargo

E. H. BOERTH Bismarck

Committee on School Health:

R. W. MC LEAN, Chairman Hillsboro

PERCY OWENS Bismarck

M. H. POINDEXTER Fargo

G. N. VIGELAND Rugby

J. P. MERRETT Valley City

R. E. DORMONT Minot

GLADYS MARTIN Dickinson

JAMES V. MILES, Jr. . . Jamestown

W. C. DAILEY’ . . . . Grand Forks

Advisonj Committee on Polio:

LEE CHRISTOFERSON, Chairman Fargo

PAUL JOHNSON Bismarck

GEORGE HART Minot

A. E. CULMER, Jr. Grand Forks

C. W. HOGAN Jamestown

J. C. SWANSON Fargo

Advisonj Committee to Public Assistance Division
of the State Welfare Board:

Representatives :

E. J. LARSON Jamestown

E. T. KELLER Rugbv

C. H. PETERS Bismarck

Liaison Committee to the North Dakota Hospital Association:

Representative: R. O. SAXVIK Jamestown

Liaison Committee to the North Dakota State Bar Association:

Representative: PAUL JOHNSON Bismarck

Liaison Committee to the North Dakota
Pharmaceutical Association:

Representative: G. A. DODDS Fargo

Liaison Committee to the \ Voman’s Auxiliary to the
North Dakota State Medical Association:

A. R. GILSDORF, Chairman Dickinson

R. H. WALDSCHMIDT Bismarck

R. W. RODGERS Dickinson

O. A. SEDLAK Fargo

E. H. BOERTH ...... Bismarck

Liaison Committee to the North Dakota
State Dental Association:

Representative: DAVID JAEHNING Wahpeton

Liaison Committe on Public Information:

Representatives :

MARLIN JOHNSON Bismarck

H. L. REICHERT Dickinson

Commission for the Improvement of Patient Care
in North Dakota:

Representatives :

A. R. GILSDORF Dickinson

R. O. SAXVIK Jamestown

Medical Center Advisory Council:

Member: P. H. WOUTAT Grand Forks

Governor’s Health Planning Committee:

Member: P. H. WOUTAT Grand Forks

State Health Council:

Members:

M. S. JACOBSON Elgin

R. F. GILLILAND Dickinson

REFERENCE COMMITTEES

1 . To consider reports of President, Secretary,

Executive Secretary, and Treasurer:

J. II. MAHONEY, Chairman Devils Lake

FRED ERENFELD Minot

A. K. JOHNSON Williston

MILTON NUGENT Bismarck

WELLDE FREY Drayton

2. To consider reports of the Council, Councillors,
and Special Committees:

R. M. FAWCETT, Chairman Devils Lake

W. L. MACAULAY Fargo

ROBERT GILLILAND Dickinson

EDMUND VINJE Hazen

V. J. FISCHER Minot

W. P. TEEVENS Grafton

3. To consider reports of the Delegate to the A.M.A.,

Medical Center Advisory Council, and Committee on
Medical Education:

KEITH FOSTER, Chairman Dickinson

R. B. TUDOR Bismarck

R. W. MC LEAN Hillsboro

R. E. MAHOWALD Grand Forks

J. S. GILLAM Fargo

4. To consider reports of Standing Committees,
except Committee on Medical Education

and Committee on Medical Economics:

A. F. HAMMARGREN, Chairman Harvey

A. R. SORENSON Minot

G. L. COUNTRYMAN Grafton

E. J. BEITHON Wahpeton

JOHN VAN DER LINDE Jamestown

5. To consider reports of Committee on Medical Economics,
including Committee on Veterans Medical Service,

Committee on Prepayment Medical Care,
and Committee on Rural Health:

CARL BAUMGARTNER, Chairman Bismarck

ARTHUR C. BURT Fargo

G. CHRISTIANSON Valley City

FRANK MELTON Fargo

6. Committee on Resolutions, to Include New Business:

T. E. PEDERSON, Chairman Jamestown

F. A. DECESARE Fargo

R. W. HENDERSON Bismarck

F. D. NAEGELI Minot

ROBERT PAINTER Grand Forks

7. Committee on Credentials:

JOHN S. GILLAM, Chairman Fargo

FRED ERENFELD Minot

PROCEEDINGS OF THE HOUSE OF DELEGATES
oi the North Dakota State Medical Association
Seventy-First Annual Meeting

The First Session of the House of Delegates of the
North Dakota State Medical Association was called to
order by the Speaker of the House, Dr. G. A. Dodds,
at 4:00 p.m. at the Clarence Parker Hotel, Minot, May 3,
1958.

Dr. John S. Gillam of Fargo, chairman of the Creden-
tials Committee, reported that there was a quorum pres-
ent and all credentials were in order.

Secretary Boerth called the roll. The following doctors
were present:

Arthur C. Burt, Fargo; Frank M. Melton, Fargo; W. L. Ma-
caulay, Fargo; F. A. DeCesare, Fargo; John S. Gillam, Fargo;
E. J. Beithon, Wahpeton; D, G. Jaehning, alternate, Wahpeton;
R. M. Fawcett, Devils Lake; J. H. Mahoney, alternate. Devils
Lake; Robert Painter, Grand Forks; G. L. Countryman, Grafton;
R. E. Mahowald, alternate. Grand Forks; W. P. Teevens, Grafton;
Wellde Frey, alternate, Drayton; V. J. Fischer, Minot; A. R. Sor-
enson, Minot; F. D. Naegeli, Minot; A. F. Hammargren, Harvey;

G. Christianson, Valley City; C. J. Klein, alternate. Valley City;
R. W. Henderson, Bismarck; Milton Nugent, Bismarck; R. B.
Tudor, Bismarck; Carl Baumgartner, Bismarck; Edmund Vinje,

SEPTEMBER 1958

383

Hazen; T. E. Pederson, Jamestown; John Van der Linde, James-
town; A. K. Johnson, Williston; Robert Gilliland, Dickinson; Keith
Foster, Dickinson; R. W. McLean, Hillsboro; and Mervin Rosen-
berg, alternate, Northwood.

There were 32 delegates present.

The following also attended the meeting of the House
of Delegates:

Drs. R. W. Rodgers, L. W. Larson, R. H. Waldschmidt, J. C.
Fawcett, R. D. Nierling, A. R. Gilsdorf, J. D. Craven, G. W.
Toomey, V. G. Borland, N. A. Youngs, C. H. Peters, D. J. Halli-
day, K. G. Vandergon, C. M. Lund, O. A. Sedlak, and Mr. Lyle
A. Limond.

Speaker Dodds instructed the alternate delegates to
assume their place on the reference committee to which
their delegate was assigned. Dr. Mahoney was asked to
assume the chairmanship of committee No. 1 to replace
Dr. Fox.

The motion was made, seconded, and passed that the
reading of the minutes be dispensed with and that they
he accepted as printed in The Journal-Lancet.

Motion was made, seconded, and passed that the read-
ing of the reports of the president, secretary, executive
secretary, and treasurer he dispensed with and that they
he referred to the proper reference committee, No. 1.

REPORT OF THE PRESIDENT

During the past year, the activities of your state asso-
ciation have been many and varied. Detailed informa-
tion is available in the handbook reports. Space and
time do not permit a recapitulation of all the work, so
my remarks will be confined to a few items, which are
felt to be most important.

It was a pleasure to be invited to visit the Southwest,
First, Northwest, Devils Lake, Sixth, Stustman, and
Grand Forks District Society Meetings, and I wish to
thank them for their cordial reception. These meetings
were all well attended and excellent programs were
given. One cannot but note, however, that there is too
little interest by the general membership in the affairs
of our association and too much apathy and lack of
knowledge about state and national legislation directly
affecting our profession. Increased effort must be made
to inform and stimulate more interest and activity. The
practice of having the delegates report the transactions
of the annual meeting to their local societies is a distinct
help and should be made mandatory. Freedom is not
something to be won once and for all but is a continu-
ing battle for all time.

In September, the National Conference on Public Re-
lations held in Chicago was attended by your state chair-
man on Public Relations (Dr. John Cartwright), the
executive secretary, and myself. It is unfortunate that
this meeting cannot be attended by every physician,
thereby better acquainting them with the vital impor-
tance of this very important subject. We must individu-
ally and collectively exert continuous effort, intelligently
directed, so that the public may have an insight into the
problems of our profession and an appreciation of our
aims and performance.

Throughout the summer of 1957, considerable coun-
trywide hysteria developed regarding an epidemic of
“Asian Flu.” The A.M.A.’s recommendation for forma-
tion of district society committees on “Asian Flu” was
followed. On September 22, I attended a joint meeting
in Bismarck of the North Dakota State Health Council
and the Public Health Committee of the state medical
association. A definite plan was formulated should the
epidemic strike North Dakota. Methods for vaccine dis-
tribution were agreed upon, and releases to the press
were aimed to inform rather than alarm the public.
Fortunately, this epidemic failed to materialize.

On November 9, 1957, I attended the meeting of the

Advisory Council on Crippled Children’s Services in
Bismarck. Among other items, the resolution presented
by the Devils Lake Society to the House of Delegates
regarding expansion of Crippled Children’s Services was
discussed. Many misconceptions of both sides were
cleared away, and I am sure we now have a much bet-
ter understanding. The necessity for careful evaluation
of economic need was emphasized, rather than leaving
the impression of an open invitation for free medical
care. The role to be played by the family physician in
requesting services was stressed. Several acute non
recurring conditions, which had previously come under
the program, were excluded.

Blue Shield had a very successful year. Enrollment is
up over 25 per cent. The cash reserves are at a very sat-
isfactory level and are steadily improving. The 10 per
cent which was temporarily withheld from the physi-
cian’s payment has been repaid. More doctors are par-
ticipating, and professional relationships are much im-
proved. On February 3, 1958, I had the pleasure of
attending the Blue Shield Public Relations meeting in
Chicago with Dr. Frank DeCesare of Fargo, Mr. Eagles,
and our own executive secretary. Many excellent papers
were presented with the keynote of service to the pro-
fession and the public. Repeatedly, emphasis was placed
on the necessity for understanding the mutual problems
of the public, the doctor, and Blue Shield. We must
continue to educate our members and the public of the
philosophy behind prepayment medical care. Blue
Shield, the backbone of this plan, alone stands between
a free practice and government medicine. The plan in
North Dakota is fully under the control of physicians.
The state society is now officially represented on the
board of directors. Consideration should be given to
having the House of Delegates officially approve the
Blue Shield schedule. On January 24, I attended the
first annual news conference of the North Dakota Hos-
pital Association in Fargo. The reason for the 30 per
cent increase in Blue Cross rates was explained. The
rising cost of hospitalization is of deep concern to every
physician. We deem expanding benefits for outpatients’
care a threatened intrusion into medical practice. This
problem was discussed at the Blue Shield-Blue Cross
Liaison Committee meeting held in Fargo on March 8.
As a guest representing the state association, I expressed
our concern regarding outpatient benefits already incor-
porated in the new Blue Shield contract, which benefits
had been added without consultation with the medical
profession. It was agreed that no further benefits would
be added until they had been discussed by the Liaison
Committee.

An innovation for selecting committee members was
introduced this year. Members of the association were
sent questionnaires requesting that each physician indi-
cate the committee in which he was most interested
and to signify willingness to work on such committee.
It was indicated that failure to reply would denote no
interest in appointment to anv committee. Those failing
to reply were not appointed. Many younger physicians
displaying interest were chosen. This questionnaire was
of great assistance in committee selection. The commit-
tees this year have worked well, and I wish to thank
the various chairmen and members for their untiring
efforts. You will note that the Economic Committee,
among other things, has adopted the relative value fee
schedule and are renegotiating fee schedules with sev-
eral agencies — Workmen’s Compensation, Welfare Board.
Indian Affairs, and Veteran’s. They have also studied
and initiated an excellent group insurance policy.

384

THE JOURNAL-LANCET

In January 1958, your negotiating team went to Wash-
ington, where the Medicare contract was renegotiated
with the Department of Defense at, again, a very satis-
factory level. This was accomplished by adequate prepa-
ration on the part of the negotiating team. Prior to going
to Washington, it had met twice in Minneapolis with
representatives of the 5 other states of the North Cen-
tral Conference and had attended the Medicare Confer-
ence held by the A.M.A. immediately following the in-
terim session in Philadelphia. The Army expressed deep
appreciation for the conduct of the plan by North Da-
kota physicians, where the average “per case” cost was
quite low. The wisdom of having an unpublished maxi-
mum schedule, which allows the physician to charge his
usual, customary, equitable fee has been fully justified.
The experience of states which published the fee sched-
ule confirms this point of view. I wish to commend Dr.
C. H. Peters of Bismarck for his invaluable work.

There was no State Legislative Assembly this year, but
there is important national legislation. Particularly im-
portant is the Forand bill, HR-9467, which would pro-
vide free hospitalization for sixty days, free nursing
home care for sixty days, and free surgery ( by the
Board of Certified Surgeons or F.A.C.S. members only)
to every recipient or those eligible for social security.
The social security tax would be raised by ’2 per cent
for the employees, Yi per cent for the employers, or &
of a per cent for the self-employed, raising the tax base
from the present $4,200 to $6,000. This bill has serious
implications, and has much popular appeal. It would
cover between ID2 and 13 million people. It represents
merely another inroad by socialism and a further inva-
sion of the free practice of medicine. We must marshal
our forces and enlist all friends of the free enterprise
system to defeat it. The voluntary prepayment plans
must formulate a way for the care of the elderly patient.

This year, ruthless attempts by officials of the United
M ine Worker’s Welfare Fund to designate the physicians
who shall provide medical care for beneficiaries of the
Welfare Fund have been evident in North Dakota. If
we permit this to continue, other agencies may be en-
couraged to adopt the same policy. It is mandatory
that the local societies and the state association recog-
nize the evil of the third party intrusion into the private
practice of medicine and institute a definite program to
combat it. The patient’s right of free choice of a physi-
cian must be maintained.

Under the excellent administration of Dr. Loeb, the
most modern and advanced methods of treating tuber-
culosis have been instituted at our State Sanatorium.
This has so reduced the patient load that he now feels
that continuation of such large sanatorium facilities are
uneconomical and that this institution might be more
profitably used for the care of other medical conditions
and suggests transferring tuberculosis patients to a more
advantageous location. Our membership should be fully
informed of all the facts. We all must realize that while
the number of tuberculous patients has been markedly
reduced, we are still faced with the problem of caring
for those who are afflicted with this disease. It is our
duty to see that a proper and equitable solution to this
problem is accomplished.

Both the public and the profession are again deeplv
indebted to Dr. Carroll Lund, who for years has con-
tinued his tireless effort in furthering cancer education.
A Cancer Caravan again traveled throughout the state
with a superlative program. If present plans materialize,
a Cancer Registry will eventually be established in every
hospital in the state.

Donations to the American Medical Education Foun-
dation are still far below an acceptable level. Too many
members of our association have not yet been convinced
that it is not only their privilege but their duty to
make an annual donation to the medical schools of
America. Our aim must be to enlist 100 per cent par-
ticipation by our membership. While compulsion is con-
trary to our belief, nevertheless, we might seriously fol-
low the lead of several other states and make this con-
tribution part of the state dues.

At the request of Dr. Myers, editor of The Journal-
Lancet, the Committee on Scientific Program was asked
to request each speaker at our annual session to supply
a copy of their papers. Publication of these excellent
papers will improve our official publication.

I very definitely feel that we are failing to utilize the
abilities of our president-elect and our first and second
vice-presidents. These offices should be given more re-
sponsibility, and perhaps their duties could be definitely
spelled out. This would not only relieve the president of
much time-consuming travel but would better prepare
his successors for the offices they will eventually assume.

To the many members who have unselfishly devoted
so much of their time and effort to the conduct of our
affairs, I wish to extend my personal thanks and grati-
tude. Their interest, loyalty, and devotion have made
the work of this office during the past year a great
pleasure. Finally, but by no means last, I wish to ex-
press my most sincere appreciation and thanks to our
very efficient executive secretary, Mr. Lyle Limond, for
his invaluable help and counsel during the past year.
His devotion to the welfare of organized medicine and
to our own state organization is deeply appreciated. It
has been a privilege and an honor to represent you at
many state and national meetings, and I am deeply
grateful for the opportunity. If I have been able to
serve you in some small way, I am happy indeed.

R. W. Rodgers, M.D., President

SECRETARY'S REPORT

MEMBERSHIP: The total membership for 1957 was
428. Of this number, 395 paid the regular membership
fee, 9 were on a retired or limited basis and 18 were
honorary members. Six members were carried on a com-
plimentary basis due to military service and age. Seven
members passed away during the year, and several have
left the state. New members, however, are being steadily
added to our roster.

Table 1 shows the annual membership for the past
five vears.

TABLE 1

COMPARISON OF ANNUAL MEMBERSHIP

1953

1954

1955

1956

1957

Paid memberships

368

378

387

380

395

Honorary memberships

12

15

14

16

18

Retired and limited

12

12

12

9

Dues cancelled, military service
and age exemption

16

6

3

8

6

Total

396

411

416

416

428

Table 2 shows the annual dues for 1958, which have
been coming in very slowly. There is still a very large
number of members who have not as yet paid their
1958 dues, and the district medical society secretaries
and councillors are urged to use every possible means to
collect the dues of these delinquent members.

SEPTEMBER 1958

385

TABLE 2

April

10

1954

April

8

1955

April

19

1956

May

1

1957

April

15

1958

Paid-up members

323

323

334

328

313

Honorary members

13

14

16

18

16

To be honorary

4

3

6

2

3

Dues cancelled, military service

4

3

5

5

3

1

1

1

Retired

6

7

3

Complimentary

1

1

Total

352

351

369

360

339

STATE ASSOCIATION MEMBERSHIPS

1957:

Regular Retired Limited Comp. Honorary

First

86

2

3

Second

27

2

Third

64

2

3

Fourth .

60

i

4

Fifth . .

7

1

Sixth

65

2

i i

3

Seventh

30

i

2

Eighth .

20

Ninth

27

3

Tenth

9

1

i

Total 395

7

2 6

18

1958:

Regular

Retired

Limited Comp.

Honorary

First

75

2

Second

16

2

Third

59

2

3

Fourth

34

1

3

Fifth

6

1

Sixth .

50

i

4

Seventh

29

i

1

Eighth

14

Ninth

23

i

Tenth

7

1

Total 313

3

4

16

A.M.A. GENERAL MEMBERSHIPS

1957

1958

First

88

74

Second

29

18

Third

68

63

Fourth

65

39

Fifth

8

7

Sixth

. 70

52

Seventh

. . . . 33

31

Eighth

20

14

Ninth

. . . . 28

24

Tenth

11

8

Total 420 330

None of the societies show paid-up membership rosters
for the current year and have forwarded only partial
reports. This is particularly noticeable in the larger dis-
tricts. The Constitution and Bylaws of the North Da-
kota State Medical Association states that such dues
should be forwarded to the state office not later than
March 1 of the current year. It should be noted that
although March 1 is the stipulated date for receipt of

dues, this report is shown as April 15 to give an up-to-
date picture of paid memberships.

The secretaiw has kept in touch with the operations
of the state office and wishes to commend Mr. Limond
and Mrs. Fremming for their cooperation in these mat-
ters of membership.

E. H. Boerth, M.D., Secretary

EXECUTIVE SECRETARY'S REPORT

MEETINGS: Your executive secretary attended sev-
eral state, regional, and national meetings in behalf of
the association and made many personal contacts with
individual physicians, newspaper editors, legislators,
radio and television personnel, hospital administrators,
nurses, attorneys, dentists, and others.

I was able to attend at least 1 meeting in 6 of the 10
district medical societies.

It is still felt, as has been reported in past years, that
some of the committees are not too active. Your state
office continues to aid in the work of those committees
which are active. Your executive secretary was present
at all but 1 committee meeting. It is again suggested
that committee meetings be held in the fall or early
winter months.

STATE OFFICE: Your headquarters office is con-

tinuing in its efforts to be of even greater service to the
total membership, to public and private health agencies,
and to the public in general.

The Medicare program and its inherent problems is
an example of the added work load of this office.

Mrs. G. K. Fremming (Margaret) continues to give
fine service as office secretary.

As you all should know, it is from here that the mem-
bership Newsletter and the auxiliary Newsletter is proc-
essed, the Physicians’ Placement Bureau functions, the
State Board of Medical Examiners’ annual license re-
newals are handled, Medicare claim forms are processed,
committee meetings are arranged and members notified,
annual association and A.M.A. dues are processed, dis-
bursement of Uniform Insurance Reporting forms is re-
corded, and the affiairs of the North Dakota Heart As-
sociation are guided, plus many other duties to numer-
ous to continue listing.

LEGISLATION: There was no action on the state
level, since this has not been a year for our legislature
to meet. On the national level, however, we are being
confronted by the inherent dangers found in the Forand
bill (HR-9467). The purpose of this bill is to amend
the Social Security Act and the Internal Revenue Code
so as to increase the benefits payable under the federal
old-age survivors and disability insurance program and
to provide insurance against the costs of hospital, nurs-
ing home, and surgical service for persons eligible for
old-age and survivors insurance benefits.

The |enkins-Keogh bills are back and should be given
support by the self-employed if they are interested in
getting up retirement plans bv deducting from "toss in-
come their annual contributions to such plans.

PHYSICIANS’ PLACEMENT SERVICE: Twenty-

seven North Dakota communities and 9 physicians or
groups are on file in this office in regard to a request
for a physician and/or additional physicians.

The 27 communities seeking a physician or an addi-
tional physician are: Anamoose, Belfield, Bowman, Buf-
falo, Finley, Flasher, Fordville, Glen Ullin, Grenora,
Hankinson, Hebron, Killdeer, Larimore, McCluskv, Mc-
Henry, Mandan, Medina, Milnor, Napoleon, New Eng-
land, Page, Pembina, Richardton, Rutland, Sharon, Stras-
burg, and Watford City. The 6 towns of those listed

386

THE JOURNAL-LANCET

having a physician but wanting 1 or more are: Bow-

man, Hankinson, Hebron, Mandan, Napoleon, and Rich-
ardton.

U.N.D. MEDICAL SCHOOL SCHOLARSHIPS: The
1957 winners of the association’s scholarship prizes, to-
taling $500, offered at the School of Medicine were:
anatomy, Robert Geston and Rollin W. Pederson (equal);
physiology and pharmacology, Richard L. Rohde; micro-
biology, lone E. Dzubur; pathology, Donald G. Mc-
Intyre, and first year, Follin W. Pederson.

FINANCE: The treasurer’s report continues to show
an improved balance. The goal of having one year’s op-
erating budget in reserve is being maintained as it should
be in the interests of good business practice.

Receipt of dues continued to be slow as in years past
as will be noted in the following chart:

District society

Number of
unpaid members

First

16

Second

( Devils Lake )

13

Third

(Grand Forks)

11

Fourth

(Northwest)

28

Fifth (

Sheyenne)

1

Sixth

19

Seventh (Stutsman)

1

Eighth

( Kotana )

6

Ninth

( Southwestern )

3

Tenth

( Traill-Steele )

3

101

Of the 101 members who have not paid, 94 are regular
members.

MEDICARE: The Dependents’ Medical Care Program
(Medicare) commenced on December 7, 1956. Up to
February 1, 1958, 710 claims had been processed by
this office.

The total sum paid to North Dakota physicians as of
January 31, 1958 is $47,156.

Each claim for services rendered averages roughly
$66.42.

Please read Dr. C. H. Peters’ report concerning the
negotiations of our new Medicare contract. These nego-
tiations took place in Washington, D.C., during January
1958.

Claim forms are still being sent to this office in an
incomplete state. It is requested that ordinary care be
exercised in having the forms filled out properly.

THOUGHTS FOR THE FUTURE:

1. Continued support should be given the State Health
Department, and particularly so, during the 1959 legis-
lative session.

2. The formation of legislative committees at the dis-
trict medical society level should be seriously considered
by the 10 component medical societies.

3. Consideration should be given to having some of
our association members visit the legislators during the
1959 legislative session, even though we are not sup-
porting or opposing any bills at the time of the visita-
tions.

ACKNOWLEDGMENTS: Your executive secretary

wishes to express his sincere appreciation to our presi-
dent, Dr. R. W. Rodgers, for his efforts in behalf of this
association. Dr. Rodgers was ever willing to leave his
busy practice to attend district society meetings and
other meetings of importance to the association.

My sincere thanks also go to those other members

with whom this writer has had occasion to work during
this past year in the association’s several programs.

Lyle A. Limond, Executive Secretary

Motion was made, seconded, and passed that the read-
ing of the reports of the council, councillors and special
committees be dispensed with and that these be referred
to reference committee No. 2 for its consideration.

Motion was made, seconded, and passed that the read-
ing of the reports of the delegate to the A.M.A., repre-
sentative to the Medical Center Advisory Council, and
Committee on Medical Education be dispensed with and
that these be referred to reference committee No. 3 for
its consideration.

Motion made, seconded, and passed that the reading
of the reports of the standing committees be dispensed
with and referred to reference committee No. 4 for con-
sideration.

Motion made, seconded, and passed that the reading
of the reports of the Committee on Medical Economics,
Committee on Veterans Medical Service, Committee on
Prepayment Medical Care, and Committee on Rural
Health be dispensed with and referred to reference com-
mittee No. 5 for consideration. At this time, Dr. Dodds
advised Dr. Baumgartner, chairman of this reference
committee, to also consider the report of Dr. Peters,
which appears in the back of the Handbook on Develop-
ment of Fee Schedule.

REPORT OF THE CHAIRMAN OF THE COUNCIL

The Council of the North Dakota State Medical Asso-
ciation had its regular spring meetings May 25 and 26
at the Gardner Hotel, Fargo, at the time of the annual
state medical meetings. There were no special meetings
ot the council in 1957. The regular interim meeting was
held December 14, 1957, at the Gardner Hotel, Fargo.

Council meeting held May 25, 1957 at the Gardner
Hotel, Fargo • — Dr. C. H. Peters reported on the prog-
ress of the Medicare program since December 7, 1956.
Several complaints had been received from individual
doctors and several of the medical societies. Dr. C. H.
Peters and Dr. R. H. Waldschmidt stated that these par-
ties had been contacted and that better satisfaction was
attained after explanation in more detail regarding the
Medicare program. Dr. Peters, who was very instru-
mental in drawing up the financial aspect of the Medi-
care program, volunteered to appear before the House
of Delegates or any reference committee to explain the
Medicare program to date.

Dr. R. H. Waldschmidt, as president of the North Da-
kota State Medical Association, recommended that the
association be represented directly on the board of di-
rectors of Blue Shield. This recommendation was car-
ried out in later council meetings. Dr. Waldschmidt em-
phasized the importance of the councillors and delegates
reporting the activities of the state medical society to
the individual district societies. He also suggested that
the Committee on prepayment Medical Care and the
Committee on Medical Economics formulate a unit plan
for the care of welfare patients and also to consider
revising the fee schedule for the Workmen’s Compensa-
tion Bureau, which he feels is too low.

Dr. Waldschmidt then spoke on the seventy-fifth anni-
versarv medical meeting, which will be held in 1962.
This meeting will be held jointly with South Dakota,
requiring special hotel and general facilities. The meet-
ing point should also be as close as possible to our
South Dakota neighbors. After much discussion, a motion
was made and seconded that Bismarck be designated the
meeting place for the seventy-fifth anniversary. The

SEPTEMBER 1958

387

motion was passed. The secretary of the council was in-
structed to convey the motion to the House of Dele-
gates, recommending that Bismarck be the meeting place
for 1962. Dr. W. A. Wright recommended that if the
state association wanted the current president of the
American Medical Association to give the anniversary
address, an invitation be extended to him as soon as
he is selected president-elect.

Dr. K. G. Vandergon reported on the progress of the
revision of the History Medical Milestones and stated
that verv little had been done since the last council
meeting. It was decided that a committee had handicaps
in editing this book, and Dr. James Halliday consented
to be chairman of the committee with the responsibility
of editing the book and having it printed. The council
voted him a free hand in this difficult problem. A mo-
tion was passed regarding “Agreement of Understand-
ing” between the North Dakota State Medical Associa-
tion and the State Board of Medical Examiners with the
North Dakota Hospital Association. A motion was passed
that the president of the state medical association ap-
point 3 members of the association and 2 members of
the board of medical examiners to a committee to meet
with the hospital association.

Dr. E. |. Larson, treasurer of the state association,
moved that $15,000 of the Association’s funds be in-
vested in government bonds. The motion was seconded
by Dr. Borland and passed.

The second session of the council was held May 26,
1957, at the Gardner Hotel, Fargo. A letter written to
Mr. Lyle Limond was read by the secretary of the North
Dakota State Dental Association requesting a liaison
committee between the North Dakota State Medical
Association and the North Dakota State Dental Associa-
tion. It was moved and seconded that the president
appoint this liaison committee with the North Dakota
Dental Association. Motion passed.

A resolution from the Devils Lake District Medical
Society, which was presented to the House of Delegates
and passed at their second session, was referred to the
council for some action. Delegates present at the time
of this council meeting stated that the resolution was
referred to the council in order to have the council im-
press upon the Crippled Children’s Bureau that no more
items should be added to the program. After much dis-
cussion, a motion was made, seconded, and passed that
the chairman of the council, Dr. A. R. Gilsdorf, com-
municate with the executive director of the State Wel-
fare Board on this matter. The results of these commu-
nications will be brought out later in this report.

A motion was made and passed that this association
turn over the Medicare program administration to the
Wisconsin State Medical Society to deal with the gov-
ernment on our contract. The Wisconsin society is better
equipped to carry out this administration than the North
Dakota association. The California Physician’s Service
Blue Shield wrote to Dr. C. II. Peters recpiesting a copy
of our Medicare fee schedule. We decided not to send
it to them, but, upon the advice of Dr. Peters, an ex-
planatory letter was sent to that organization by Mr.
Lyle Limond.

Chairman of the council. Dr. A. R. Gilsdorf, appoint-
ed Dr. V. G. Borland and Dr. Keith Vandergon as 2
members to serve on the Blue Shield board of directors
with the speaker of the House of Delegates, Dr. G. A.
Dodds. These appointees were specifically made to ful-
fill the request of Dr. Waldsclnnidt, as noted under the
report of the council meeting of Saturday, May 25, 1957.

After much discussion, a motion was made, seconded,
and passed that the council suggest to the district med-

ical societies that the Tuesday evening dinner at the
annual meetings be discontinued, as attendance was
not good and it was a burden to society members in the
towns in which the meetings were held and that these
dinners did not serve a sufficiently useful purpose to be
continued.

Election of officers was held and the following doctors
were elected unanimously: A. R. Gilsdorf, chairman of
the council; R. D. Nierling, vice-chairman; and W. H.
Gilsdorf, secretary.

The executive committee of the council will consist
of these 3 officers.

The next interim meeting was set for December 7,
1957, at the Gardner Hotel, Fargo.

As previously stated, the chairman of the council, on
the recommendation of the House of Delegates and the
council, corresponded with the Public Welfare Board of
North Dakota regarding the Crippled Children’s pro-
gram.

On May 26, 1957, the chairman of the council, Dr.
A. R. Gilsdorf, wrote to Carlyle D. Onsrud, executive
director of the State Welfare Board at Bismarck. The
Devils Lake District Medical Society’s resolution voicing
its objection to expanding the Crippled Children’s pro-
gram was quoted to Mr. Onsrud. Following a one-
page explanation regarding the action of the House of
Delegates and the council, the letter was finished with
the following remarks, “May we suggest that the State
Welfare Board Committee on Crippled Children meet
jointly with the Committee on Crippled Children of the
North Dakota State Medical Association and review this
problem.” It is to be noted that this correspondence is
in regard to a directive of the Public Welfare Board of
North Dakota dated December 20, 1956, signed by
Paul L. Johnson, M.D., acting medical director of the
Crippled Children’s Services.

On June 6, 1957, I received a letter from Carlyle D.
Onsrud in answer to my letter of May 26. Mr. Onsrud’s
letter imparted a feeling of desire for helpful coopera-
tion. Extracted from his one-page letter was the follow-
ing, “We welcome a session on the subject matter you
enumerated between the administrative and professional
advisory personnel of the State Welfare Board and your
Association on the Crippled Children’s Program. Perhaps
you and your Association could suggest an appropriate
date for this conference.”

I received a letter written by Grover D. Icenogle,
M.D., dated June 10, 1957, acknowledging the receipt
of the copy of the letter to Mr. Onsrud and noting that
he woidd further discuss the matter. During this in-
terim from the time of the directive of December 20,

1956, signed by Paul L. Johnson, M.D., Dr. Icenogle
was appointed medical director of the Crippled Chil-
dren’s Services.

This was the last official correspondence of the chair-
man of the council regarding the Crippled Children’s
program, but further correspondence and meetings were
held between the present North Dakota State Medical
Association president, Dr. R. W. Rodgers, and the mem-
bers of the Crippled Children’s Bureau. Apparently, a
more satisfactory understanding has been reached be-
tween the Crippled Children’s Bureau and the state asso-
ciation.

The regular interim meeting date was changed from
December 7 to December 14, 1957, because of other
national medical meetings. This meeting was also held
in the Gardner Hotel, Fargo. Dr. W. 11. Gilsdorf of
Valley Citv, secretary of the council, died September 20.

1957. A motion was made and carried that Dr. C. II.
Peters be appointed secretary, and a motion was carried

388

THE JOURNAL-LANCET

that Dr. Guilder Chrstianson succeed the late Dr. Walter
Gilsdorf to the council.

Mr. Oscar Hanson of Grand Forks, general agent for
the Union Central Life Insurance Company, spoke con-
cerning the group life insurance proposal for the mem-
bers of the North Dakota State Medical Association. It
was stated that the number of our members required to
put the policy in force was 100, and 25 were required in
order to keep the policy in force. Members of the coun-
cil felt that the program of this company was commend-
able and it could be recommended to association mem-
bers. Mr. Hanson then offered to send brochures to each
doctor of the state society.

Mr. James Dixon and Mr. Ed Boerth of Fargo pre-
sented a proposal for a professional liability ( malprac-
tice) insurance program. In the discussion on this mal-
practice program, it was noted that a group policy is
less expensive. Minimum members required would be
100. Maximum protection for an individual would be
$100,000 to $300,000. In groups, it would be $100,000
to $600,000. The membership of the North Dakota State
Medical Association would have to be surveyed for ac-
ceptability, and a claims committee would be needed.
Messrs. Dixon and Boerth of Insurance, Inc., Fargo,
would cooperate in the survey by supplying small poli-
cies and brochures. The council felt that the president
of the North Dakota State Medical Association could
appoint a claims committee in cooperation with Messrs.
Dixon and Boerth. The council in general felt that such
an approach to malpractice insurance is good and we
favored further action by Messrs. Dixon and Boerth.

Dr. Halliday reported on hs personal survey of the
book, Medical Milestones in North Dakota, and stated
that many gross errors were found. He further stated
that the book would have to be rewritten. It was de-
cided that a new start be made on the book and to
have it ready for the seventy-fifth anniversary meeting.

A motion was carried to deny exhibit space request
by a Minot chiropodist for the 1958 meeting.

The council clarified the wording of the motion made
and carried at the December 1956 interim meeting re-
garding charges for the Sunday night “Mixer” included
as part of the annual meetings. The clarification is as
follows: “Each physician is to be charged $5.00 to
attend the “Mixer” and his lady is also to be charged
$5.00. Exhibitors (both scientific and technical), guest
speakers, and employees of the North Dakota State Med-
ical Association are to be guests of the association.”

The council approved a motion that the Committee
on Geriatrics and Rehabilitation act as an advisory com-
mittee to the Rehabilitation Unit at the University of
North Dakota.

The motion was carried that a small committee be
appointed to act as an advisory committee to a Shel-
tered Workshop to be built in Jamestown by the North
Dakota Society for Crippled Children and Adults (Eas-
ter Seal Society).

A motion was carried that prizes of $50, $25, and $10
be underwritten by the association for the A.A.P.S.
essay contest. The prize money is to be charged to the
Public Relations Budget.

Dr. Peters spoke on the coming renegotiation of the
Medicare contract. The contract is not to be signed until
members of the executive committee give their approval.
Dr. Peters moved and Dr. Waldschmidt seconded that
the fiscal agent for the North Dakota State Medical
Association, under the Medicare contract, should con-
tinue to be the State Medical Society of Wisconsin.
Motion carried.

Discussions were brought out by Dr. D. J. Halliday
and our president, Dr. R. W. Rodgers, regarding the
United Mine Workers and their attitude toward the pri-
vate practice of medicine. It was suggested that the
local district medical societies might wish to invite a
representative of the United Mine Workers to discuss
these problems with the membership.

Our president, Dr. R. W. Rodgers, spoke on the For-
and bill, the A.M.E.F., and other items of interest.

The proposed budget for 1958 was, at this time, ap-
proved by the council.

It is to be noted that the budget appears to be less
because of the reduced figure under Committee on
Necrology and Medical History. This does not mean,
however, that the total operating expense of our asso-
ciation has dropped, but that the delay in publication
of Medical Milestones has temporarily held up the ex-
penditure of this money. We must keep our budget high
and our cash reserves high because of unexpected ex-
penses relating especially to the committees on Public
Relations and Legislation as well as any change that
may come up at the time of publication of our book.

The president of the association, Dr. R. W. Rodgers,
contacted the chairman of the council, Dr. A. R. Gils-
dorf, on February 17, 1958, regarding the problem in-
volved in the possible closing of the North Dakota Sana-
torium for Tuberculosis at Dunseith. Dr. Rodgers
thought that the association could not wait for the an-
nual spring meeting to make a decision as to whether
or not there should be an additional survey of the tuber-
culosis situation within our state. The closing paragraph
of Dr. Rodgers’ letter to Dr. Gilsdorf is as follows:

“In view of this expression of opinion by so many
members of our State Medical Association, I believe,
that as the official body of the North Dakota State
Medical Association, it becomes our duty to make a
request to the United States Public Health Service
that a definite survey of our State’s needs, in regard
to this problem, be made at the earliest possible date,
requesting that they submit recommendations as to:
(A) What present and future facilities will be needed
for the adequate and proper care of patients afflicted
with tuberculosis. ( B ) Where such facilities would
most profitably be located. Therefore, Dr. Gilsdorf,

I would recommend that you contact the members of
the Council, presenting the problem to them and re-
questing what action they wish to take regarding the
request for such a survey.

Very truly yours,

R. W. Rodgers, M.D., President”

In response to Dr. Rodgers’ letter, the chairman of
the council sent an explanatory letter to each member
of the council with a request for his vote and opinion.
A majority vote by the council was received, indicating
that further survey was desired. This information was
passed to Dr. Rodgers who took further action on this
problem. At the time of writing this report, no definite
decision has yet been made as to how North Dakota
will house the patients if Dunseith’s sanatorium is closed.

Dr. Nierling moved and Dr. Toomey seconded that
the North Dakota State Medical Association offer its co-
operation to the Division of Vital Statistics of the State
Health Department on a survey dealing with cancer
deaths thought to be due to cancer of the lung caused
by smoking. Motion was carried.

A. R. Gilsdorf, M.D.,
Chairman of the Council

389

SEPTEMBER 1958

REPORTS OF COUNCILLORS
First District

The First District Medical Society held 9 meetings
during 1957. All meetings were held in the Town Hall
of the Gardner Hotel. The following officers were elect-
ed for the year: president, Dr. R. D. Weible; vice-

president, Dr. L. G. Pray; and secretary-treasurer, Dr.
A. L. Klein.

Dr. A. C. Burt requested and the society approved
a cancer registry program for St. John’s Hospital. Mr.
Donald Eagles gave a report on Blue Cross and Blue
Shield, discussing their programs and plans for the
future. The scientific portion of the program was pre-
sented by Dr. Bailey, consultant in neurology at the
Mayo Clinic, on “Convulsive Disorders.”

Dr. R. H. Waldsclnnidt, president of the North Da-
kota State Medical Society, was present, and outlined
some of the problems of the society. Dr. Carroll Lund
and Mr. Lyle Limond were guests at this meeting. Mrs.
Snyder, of the North Dakota State Cancer Committee,
outlined a few pertinent facts about the Cancer Caravan
in North Dakota. Speakers for the evening were Dr. R.
R. Tyson and Dr. |. B. Emich of Temple University,
Philadelphia.

At the September meeting, Dr. Merrill Chesler, clin-
ical instructor in surgery at the University of Minne-
sota, spoke on “Plastic Surgery.” Dr. R. II. Waldsclnnidt
was again present and addressed the society with par-
ticular reference to new legislation.

At the October meeting, Dr. Claude Hitchcock, asso-
ciate professor of surgery at the University of Minne-
sota, gave a talk on “Emergency Management of Seri-
ously Injured People.”

At the November meeting, Miss Landon, auxiliary
director of the Rehabilitation Unit in North Dakota, was
introduced by Dr. Harwood and talked on the work of
her unit in North Dakota. The society voted to contrib-
ute up to $200 toward the essay contest of the American
Association of Physicians and Surgeons. Motion was
made and carried that a I leart Council be established in
this area. Dr. Lancaster discussed the Forand bill.

The December meeting was devoted to a social gath-
ering, and, as is our custom at this meeting, no scientific
program was presented. The following officers were
elected for 1958: president, Dr. L. G. Pray; vice-presi-
dent, Dr. A. L. Klein; and secretary -treasurer, Dr. Frank
M. Melton. Delegates to the state convention are: Drs.
A. C. Burt, E. J. Beithon, F. M. Melton, W. L. Ma-
caulay, F. A. DeCesare, and J. S. Gillam. Dr. E. M.
Haugrud was elected censor.

V. C. Borland, M.D., Councillor
Second District

The Second District Medical Society held 9 regular
scheduled meetings during 1957. The attendance at
the meetings was excellent throughout the year.

New members accepted into the society during the
year were: Dr. Stuart J. Cook, Rolette; Dr. William

Gorrie, Maddock; Dr. Jerrold A. Munro, Rolla; and Dr.
John Anthony, Leeds. Dr. Simpson, who had been ad-
mitted into the society, transferred to the Grand Forks
District Medical Society. At the present time, all of the
new men in the district are now members of the society.

Officers elected for 1958 are: president, Dr. G. H.
Hilts, Cando; vice-president, Dr. W. A. Gorrie, Mad-
dock; and secretary-treasurer. Dr. Louis F. Pine, Devils
Lake. Delegates: Dr. William Fox, Rugby; and Dr. R.
M. Fawcett, Devils Lake. Alternate delegates: Dr. D.
W. Palmer, Cando; and Dr. J. H. Mahoney, Devils Lake.
Censor: Dr. G. W. Seibel, New Rockford.

Scientific programs were held at each of the meetings,
all of which were conducted by out-of-town speakers.
On several occasions, lay speakers were brought in and
it was felt throughout the society that some of these
were very boring and uninteresting. It was felt that, in
the future, we could probably dispense with some of
these talks.

Programs included surgical aspects of thyroid disease
by Drs. Jack Revere and Phil Berger of Grand Forks.
Thromboembolism and thrombophlebitis were discussed
by Dr. Keig of Grand Forks. In April, we were favored
with the Cancer Caravan and the presence of Dr. Wald-
schmidt, president of the association at that time. Med-
ical phases and surgical phases of cardiac surgery were
discussed by Drs. Brandenburg and Bernatz of the Mayo
Clinic.

The September 12 meeting was held at Cando. Dr.
Dodds of Fargo discussed chest injuries. In November,
Dr. Rodgers visited the society and presented the prob-
lems that we are facing at the present time. At the
December meeting, Dr. Marvin of the University of
Minnesota Hospitals spoke on radiation hazards.

During the year, several problems were brought up at
the various meetings. Most notable was a lengthy discus-
sion at the January meeting concerning the expansion
of the Crippled Children’s program. It was felt that the
expansion was unwarranted and many phases of it were
infringing upon the rights of the general practitioner.
The secretary of the society was instructed to write a
letter to Dr. Paul Johnson, stating the feeling of the
society on this matter. At the request of Dr. Wald-
selnnidt, a committee was appointed to head a local
campaign for the purpose of publicizing the vaccination
of people under 40 with Salk vaccine. At the September
meeting, there was considerable discussion regarding the
Welfare Board and physician relationship, the feeling be-
ing that members did not approve of the Welfare Board
paying the patient directly and the patient, in turn, the
physician. It was felt there was considerable inequity
in this situation, the hospitals being paid by the Welfare
Board but not the physician. However, as long as this
is a federal ruling, it was felt that little could be done
about it at the present time.

At the December meeting, quite a lengthy discussion
was held regarding methods of combating prepaid in-
dustrial health plans. Free choice of physicians was con-
sidered an absolute essential.

The Devils Lake District Society contributed $25 to
the support of the essay contest. It was felt this was
possibly a very good method of building up better public
relations. However, in the past, response to this project
has been disappointing.

G. W. Toomey, M.D., Councillor

Third District

The Grand Forks District Medical Society has a cur-
rent membership of 70. The following officers were
elected at our last annual meeting: president. Dr. John
A. Sandmeyer, Grand Forks; vice-president, Dr. H. R.
Piltingsrud, Park River; and secretary-treasurer, Dr.
Wallace Nelson, Grand Forks.

The past year has been one of smooth fellowship
without incidence to mar the steady progress of this
society.

Nelson A. Youngs, M.D., Councillor

Fourth District

Nine meetings were held by the Fourth District dur-
ing the past year.

On March 28, Dr. Kling of Bismarck gave a very in-

390

THE JOURNAL-LANCET

formative talk on problems as they apply to the pa-
thologist.

On April 25, Dr. Waldsehmidt, president of the State
Medical Association, honored the society with a talk
about the activities of the association. He urged that
the delegates to the state meeting be called upon during
the early fall to give the society members a report of the
business that is transacted in the House of Delegates.
He also spoke on and answered questions relative to the
Medicare program.

May 17, Dr. E. Evans, from the University of Min-
nesota, spoke on “The Modern Concepts in the Treat-
ment of Osseous Tuberculosis.”

At the meeting on October 24, a full report was given
bv the several delegates attending the state meeting in
Fargo. Also present at this meeting were Dr. Rodgers,
state president, and Mr. Lyle Limond, executive secre-
tary of the association. Both reviewed the problems and
activities of the association.

November 14, Dr. Loken, from the University of Min-
nesota, read a paper on “Radiation Hazards.”

December 16, Dr. Richardson, pathologist at St. Jo-
seph’s Hospital in Minot, showed a film on “Cytological
Screening of Cancer.”

January 17, Dr. Green of Rochester, Minnesota, gave
a paper on “Asymptomatic Microhematuria.”

February 27, Dr. James Masson, from the Mayo
Clinic, spoke on “Surgery of the Head and Neck.” Dr.
O. A. Sedlak and Mr. Don Eagles of Fargo were present
and reviewed the Blue Shield program.

Officers elected at the January meeting are: president,
Dr. W. B. Huntley; vice-president. Dr. Samuel Shea;
and secretary-treasurer, Dr. R. A. Vaaler.

During the year, 8 new members were accepted. Four
members transferred elsewhere. Total membership is 67;
63 are active members and 4 are retired or honorary
members.

D. J. Halliday, M.D., Councillor

Fifth District

The Sheyenne Valley Medical Society held 7 meet-
ings during 1957. Membership now numbers 7 with the
addition of Dr. T. A. Harris of Cooperstown as a new
member. Officers elected to serve for the year of 1958
are: president, Dr. G. Christianson; vice-president, Dr,
J. P. Merrett; and secretary-treasurer, Dr. C. J. Klein.
Delegate: Dr. N. A. Macdonald. Alternate delegate:
Dr. C. J. Klein.

Due to the untimely death of Dr. W. H. Gilsdorf,
Dr. G. Christianson was elected to serve out Dr. C.ils-
dorf’s term as councillor for the Fifth District.

Scientific meetings consisted of several Upjohn Com-
pany Grand Rounds films. The topics were: “Borderline
Cases of Carcinoma,” “Carcinoma of the Breast and
Colon,” and “Therapeutic Advances in Liver Disease.”

Dr. F. L. Behling, of Fargo, spoke on “Treatment of
Vascular Occlusion of the Lower Extremity.” Miss
Frances Landon, of the University of North Dakota,
spoke in regard to rehabilitation facilities available at
the new Rehabilitation Center at the University.

The society was saddened by the death of Dr. W. H.
Gilsdorf on Friday, September 20, 1957, after a very
short illness.

The North Dakota chapter of A.A.G.P. held its meet-
ing in Valley City in December 1957.

G. Christianson, M.D., Councillor

Sixth District

This society held 4 meetings during 1957, with an
average attendance of 45 members. The total member-

ship at the end of the year 1957 was 65. The officers for
1957 were: president, Dr. Phillip Blumenthal, Mandan;
vice-president, Dr. Herman |. Bertheau, Linton; and
secretary-treasurer, Dr. Robert D. Sehoregge, Bismarck.
Members of the House of Delegates from this district
were: Dr. R. B. Tudor, Bismarck; Dr. Carl J. Baumgart-
ner, Bismarck; Dr. M. E. Nugent, Bismarck; Dr. M. S.
Jacobson, Elgin; and Dr. R. VV. Henderson, Bismarck.
The Board of Censors were: Dr. G. R. Lipp, Dr. Percy
Owens, and Dr. E. D. Perrin, all of Bismarck.

The guest at our first meting was Dr. Robert Branden-
burg, of the Department of Cardiology, Rochester, Min-
nesota, who spoke on “Newer Techniques in Cardiac In-
vestigation and Diagnoses.”

The next regular meeting of the society was held
May 2, 1957, under auspices of the North Dakota Cancer
Society. The main speakers of the evening were Mrs.
Mary Snyder, executive director of the North Dakota
Cancer Society; and Dr. R. R. Tyson and Dr. J. B.
Emich, of Temple University, Philadelphia. Dr. R. II.
Waldsehmidt, President of the North Dakota State Med-
ical Society, also gave a resume of the association’s prob-
lems at this time. The topic for the evening was “A
Symposium for Surgery in the Elderly Patient.”

The third regular meeting of the society was held on
October 25, 1957. The guest speaker of the evening was
Dr. Ulf Rudhe, of the Karoline Institute of Stockholm,
Sweden. He spoke on “Radiological Abnormalities of the
Urinary Tract in Children.” At this meeting, it was also
moved and carried unanimously that the delegates from
this district give a report of the state meeting at the
first meeting of the district society after the annual meet-
ing of the state association.

The last regular meeting of this society was held on
December 4, 1957. The guest speakers for the evening
included Mr. Edward L. Sypnieski, executive director of
the North Dakota Tuberculosis and Health Association
and Dr. James F. Marvin, assistant professor of radiology
at the Lhiiversity of Minnesota, who spoke on “Radiation
Hazards.”

Members who joined the Sixth District Medical So-
ciety in 1957 are: Dr. H. P. Smeenk, Bismarck; Dr. A.
F. Samuelson, Bismarck; Dr. Harvey S. Brodovskv, Bis-
marck; and Dr. W. J. McGee, Riverdale (transfer).

C. H. Peters, M.D., Councillor
Seventh District

Six meetings of the Seventh District Medical Society
were held from May 1, 1957, through March 21, 1958.

May 1, 1957 — The annual Cancer Caravan visited
Jamestown. Dr. John B. Emich spoke upon the subject
of “Cancer in the Female,” and Dr. Robert R. Tyson
spoke on “Cancer Surgery in the Elderlv Patient.” Both
men are members of the staff of Temple University,
Philadelphia. Dr. R. H. Waldsehmidt, president of the
North Dakota State Medical Association; Mr. Lyle Li-
mond, executive secretary; Dr. Carroll Lund, coordi-
nator of the Caravan; and Dr. Walter Gilsdorf and Dr.
Clifford Klein of Valley City were guests.

September 26, 1957 — The first meeting of the fall was
held at the Moline Cafe. Dr. Robert MacDonald, of
Gackle, was voted active membership in the society.
Dr. T. E. Pederson, alternate delegate to the A.M.A.,
reported on the House of Delegates proceedings at the
A.M.A. Convention in New York in June. He also re-
ported on the House of Delegates meeting at the state
meeting in May. Dr. Nierling added a few remarks
concerning the council’s activities as well as some re-
marks on the scientific sessions of the A.M.A. A Grand
Rounds film. No. 4, “Pre-Malignant and Malignant Le-

SEPTEMBER 1958

391

sions of the Breast and Colon,” sponsored by the Upjohn
Company, concluded the meeting.

December 2, 1957— This meeting was held at the
Jamestown Hospital. Six local dentists were guests at
the meeting. The Woman’s Auxiliary is sponsoring the
annual essay contest. A Poison Control Center is being
set up in Jamestown and this was described by Dr.
Miles. The main program was sponsored by the North
Dakota Tuberculosis and Health Association. Dr. James
V. Marvin, associate professor of radiology at the Uni-
versity of Minnesota, spoke on “Radiation Hazards in
Medical Practice.”

January 23, 1958 — -The following officers were elected
for the year: president, Russell O. Saxvik; vice-president,
Ellis Oster; and secretary-treasurer, R. D. Nierling.
Delegates: T. E. Pederson and John Van der Linde.
Alternate delegates: Russell O. Saxvik and J. N. Els-
worth. Censors: three years, Edwin O. Hieb; two years,
John Van der Linde; and one year, Ellis Oster.

Guests for the evening were Mr. Lvle Limond, execu-
tive secretary; Dr. M. Sakai, pathologist; and Miss Fran-
ces Landon, executive director of the University Re-
habilitation Unit in Grand Forks. Tbe society voted to
give the Science Fair $75. Miss Landon spoke on the
needs of habilitation and rehabilitation, describing the
services available to the patients at the Center at Grand
Forks and also mentioning the further needs of the
Center, mainly dormitory and children’s facilities. Films
on “Bedside Diagnoses of Fluid Balance Problems” and
Grand Rounds film No. 5, “Diagnostic and Therapeutic
Advances in Liver Disease” concluded the program.

February 28, 1958 — The meeting was held at the
Jamestown Hospital. Guests for the evening were Dr.
R. W. Rodgers, state president; Mr. Lvle Limond, execu-
tive secretary; and Dr. George Loeb, superintendent of
the State Tuberculosis Sanatorium. Dr. Rodgers dis-
cussed the Medicare program, Blue Shield problems, the
Forand bill coming up before Congress, the United Mine
Workers contract, and the American Medical Education
Foundation. Dr. Loeb spoke on the disposition of the
State Sanatorium in San Haven and then followed with
a discussion of the incidence, diagnosis, and treatment of
pulmonary tuberculosis. In 1953, there were 214 new
cases, and this number has decreased yearly since. In
1957, there were 112 cases, and most of these were not
far advanced. He felt that the mobile x-ray units have
outlived their usefulness and that x-rays of susceptible
groups and contacts should be done. Skin testing should
be universal. Drugs and surgery have replaced phrenic
nerve crushing, pneumothorax, and pneumoperitoneum.
Following the meeting, Dr. Loeb showed many x-rays.

March 21, 1958 — The Annual Cancer Caravan was
held at Jamestown Hospital. Nine local dentists were
guests of the society for the evening and also Dr. R. W.
Rodgers, state president; Dr. Carrol Lund, coordinator
of the Caravan; Mr. Lyle Limond, executive secretary,
as well as the speakers for the evening, Drs. William II.
ReMine and James K. Masson of the Mayo Clinic. Fol-
lowing the dinner, Dr. Saxvik opened the meeting by
welcoming the dentists. Dr. B. V. Nierling, president of
the local dental society, responded. Dr. R. W. Rodgers
introduced the guest speakers. Dr. James K. Masson
spoke first on tbe subject of “Benign and Malignant Le-
sions in the Oral Cavity.” Dr. William H. ReMine fol-
lowed with an address on “Lesions of the Neck and
Cervical Region.” Many colored slides were shown of
the various lesions of the oral cavity and neck, and some
of the slides depicted the surgical procedures done for
the purpose of removing these lesions. Dr. Masson is in

the Plastic Surgery Division of the Mayo Clinic and Dr.
ReMine in general surgery at the clinic. A question and
answer period followed. A brief business meeting fol-
lowed with Dr. Nierling announcing Medical Education
Week — April 20 to 27. A Grand Rounds film on “Car-
diac Stress” is to be shown at the Jamestown Hospital
March 26, and the annual Science Fair is to be held
March 28 and 29 at the High School.

A meeting of the society will be held the latter part
of April, at which time Dr. Lee A. Christoferson, of
Fargo, will address the group on “Head Injuries and
Their Management.”

There are 30 members of the society at the present
time — 1 new member having been added during the year
and 2 lost as the result of moving from the district.

R. D. Nierling, M.D., Councillor

Eighth District

The Eighth District Medical Society is comprised of
physicians practicing in Watford City, Tioga, Crosby,
and Williston, currently numbering 19 members.

On April 23, 1957, the quarterly meeting of the so-
ciety was held at the El Rancho dining room. Two emi-
nent speakers, Dr. Wilcox and Dr. Selp of Columbia
University, presented papers on the “Elderly Cancer
Patient.”

November 15, 1957, the society convened at the Elks’
Home for a dinner meeting and scientific program. M.
R. Loken, Ph.D., was the guest speaker and spoke on
“Radiation Hazards in Medical Practice.” Dr. Loken is
assistant professor of radiology at the University of Min-
nesota. He presented research data as well as useful,
practical information. The meeting and dinner was en-
joyed by all.

On January 22, 1958, the society’s annual business
meeting was held at the Williston Clinic. The following
officers were elected for the ensuing year: president.
Dr. Joe Craven; vice-president, Dr. Duane Pile; and
secretary-treasurer, Dr. Andrew Sathe. Delegate: Dr.
Alan Johnson. Alternate: Dr. Dean Strinden.

At this meeting, Don Eagles, of Blue Cross, and Dr.
O. A. Sedlak, medical director of Blue Cross, were guest
speakers and explained the program and Blue Cross
plans for 1958 and the future. This was followed by a
question and answer period.

Joseph D. Craven, M.D., Councillor

Ninth District

The Southwestern District Medical Society held 8
official meetings in 1957. We have 29 members, 3 of
whom are retired.

The first meeting was held February 9, 1957, at the
Dickinson Elks’ Club where dinner was served to mem-
bers and their wives. The doctors then went to St. Jo-
seph’s Hospital where the Grand Rounds movie was
shown.

The second meeting was held April 13, 1957. The
polio campaign was discussed. A uniform polio vac-
cination charge was discussed, and $10 for the 3 injec-
tions was suggested. We were also addressed bv Mr.
Don Eagles, of the North Dakota Blue Shield. Dr.
Charles Arneson, of Bismarck, discussed “Medicine and
the State Legislation.”

The third meeting was held May 3, 1957, and in-
cluded a Cancer Caravan evening. The state president.
Dr. Waldschmidt, was present and spoke on state med-
ical society activities. Some medical administrator prob-
lems were discussed by Mr. Lvle Limond, our executive
secretary. Dr. C. M. Lund introduced Dr. R. Robert
Tysan, Temple University, and Dr. John P. Emich, also

392

THE JOURNAL-LANCET

of Temple, who lectured on “Surgery and the Elderly
Cancer Patient.” Mrs. Mary Snyder, executive director
of the North Dakota Division of the American Cancer
Society also spoke to us.

The fourth meeting was held June 8, 1957. Since
this meeting was the first following the annual state
meeting, which was held May 25 and 26 at Fargo, sev-
eral officer reports were made. Dr. Keith Foster gave a
report on action taken by the House of Delegates. Dr.
A. R. Gilsdorf reported on the meetings of the council.
Our new state president, Dr. R. W. Rodgers, gave a de-
tailed discussion on the problems facing the state med-
ical society for the coming year. He also spoke on the
problems facing the local society. After this meeting, a
film on “Anticoagulants” was shown.

The fifth meeting was held August 10, 1957. “Asiatic
Flu” was discussed. A letter was received from the State
Tuberculosis Association regarding their activities. Our
secretary was instructed to write to them stating our
desire to participate in their program. Another Grand
Rounds film was shown.

The sixth meeting was held October 12, 1957. This
meeting was dedicated essentially to discussions on med-
ical emergencies. Dr. Gladys E. Martin discussed med-
ical emergencies in children. Dr. Keith Foster discussed
this subject from the internist’s aspect. Dr. D. |. Rei-
chert discussed medical emergencies in relation to eye
injuries.

The seventh meeting was held November 9, 1957.
Correspondence received from Miss Frances D. Landon,
executive secretary of the Medical Rehabilitation Unit of
North Dakota, was discussed. Correspondence was also
received from the American Psychiatric Association re-
questing suggestions from the general practitioners for
postgraduate courses in psychiatry. A scientific paper
was delivered by Merle Loken, Ph.D., assistant professor
of radiology at the University of Minnesota, on “Hazards
of Radiation.”

The final meeting was held December 14, 1957. A
letter from Mrs. L. T. Longmire, of Devils Lake, was
read requesting prize money for an essay contest spon-
sored by the Association of American Physicians and
Surgeons. Seventy-five dollars was allotted from our
local treasury.

The following officers were elected: president, Dr.
Robert E. Hankins, Mott; vice-president, Dr. R. F.
Raasch, Dickinson; and secretary-treasurer, Dr. D. J.
Reichert, Dickinson. Delegates: Dr. Keith Foster, Dick-
inson; and Dr. R. F. Gilliland, Dickinson. Alternate dele-
gates: Dr. W. C. Hanewald, Richardton; and Dr. Julian
Tosky, Hebron. Councillors: Dr. W. M. Buckingham,
Elgin; Dr. R. J. Dukart, Dickinson; and Dr. A. J.
Gumper, Dickinson.

Members appointed to the North Dakota Physicians
Service Corporation were: Dr. Keith Foster, Dickinson;
Dr. R. F. Gilliland, Dickinson; Dr. A. R. Gilsdorf, Dick-
inson; and Dr. R. W. Rodgers, Dickinson.

Appointed to the North Dakota Physician Service
Board of Directors was Dr. R. W. Rodgers, Dickinson.

During the year 1957, 2 of our members transferred —
Dr. Robert Goulding, of Bowman, to California; and Dr.
James Moses, of Richardton, to California. Two mem-
bers came into our society — Dr. Knickerbocker moved
to Hettinger, and Dr. Robert Thom moved to Bowman.

A. R. Gilsdohf, M.D., Councillor

Tenth District

The Tenth District Medical Society held 4 official
meetings in 1957. Three of the meetings were held in

Mayville, while a spring meeting was held at Dr. and
Mrs. McLean’s home in Hillsboro.

Each was a dinner meeting followed by a scientific
meeting and then coffee at one of the doctors’ homes.

The first meeting was held in Mayville on April 10,
1957, at which time Mr. Don Eagles talked on the
operations of Blue Shield.

The second meeting was held in Hillsboro on May 8,
1957. We were guests of Drs. McLean and Mergens.
As the scientific portion of our program, we were shown
the latest Grand Rrounds film.

Our next meeting was held in Mayville on October 2,
1957, and, again, we used the Grand Rounds film for
our scientific session.

Our last meeting of the year was held October 30,
1957, in Mayville. For the scientific session we used
another Grand Rounds film. Following is a list of the
officers elected for 1958: president, Dr. R. C. Little;
vice-president, Dr. K. G. Vandergon; and secretary-
treasurer, Dr. R. W. McLean. Delegate: Dr. R. W. Mc-
Lean. Alternate delegate: Dr. Mervin Rosenberg.

Corporate members of Blue Shield: Dr. K. G. Van-
dergon and Dr. R. W. McLean. Censors: three years,
Dr. R. C. Little; two years, Dr. D. N. Mergens; and one
year, Dr. H. A. LaFleur.

There have been no changes in membership in the
year of 1957. We continue to have 8 active members,

1 retired member, and 1 member in the Air Force.

K. G. Vandergon, M.D.

COMMITTEE REPORTS
Committee on Mental Health

The chairman of the Committee on Mental Health
failed to call a meeting this year. This is indeed un-
fortunate as a number of trends and current events
should have the consideration and recommendation of
the Committee on Mental Health and the State Medical
Association itself.

These trends and events include the mushrooming
use of tranquilizing medications, the development of at
least 2 county mental health associations, the efforts of
public welfare agencies to provide greater amounts of
services to families and children with mental or emo-
tional problems, the increasing awareness of the needs
and lack of facilities for care and treatment of emo-
tionally disturbed children, and increasing programs di-
rected toward mental health education both in formal
educational systems and for adult education.

In order for the Committee on Mental Health to carry
out its duties and functions, I should like to suggest
appointment of a new energetic chairman, and, second,
because of the scattered geographic location of the mem-
bers of the committee, that permission be given to hold
an “Eastern” and a “Western” meeting or meetings with
less than a quorum. The reason for this is that no matter
where a meeting might be held, some members of the
committee would be at least 200 miles away from the
meeting place.

John G. Freeman, M.D., Chairman

Committee on School Health

There was no official meeting of the School Health
Committee during this past year. However, as a follow-
up on the Mental Health Education report of the year
before and the approval of the House of Delegates, the
chairman of the School Health Committee met with and
accepted a membership on the Board of Directors of the
North Dakota Association for the Mentally Retarded.

Your chairman plans to work with this association to

SEPTEMBER 1958

393

accomplish what can be done for the educable children
under our school health recommendations.

R. W. McLean, M.D., Chairman

Committee on Diabetes

The Committee on Diabetes, whose primary function
is to encourage and coordinate annual diabetes detection
drives throughout the state under sponsorship of con-
stituent local medical societies, has very little to report
for the year 1957-1958.

Unfortunately, no detection drives were held by any
of the district medical societies throughout the state ex-
cept in Grand Forks where a modest drive was held in
November, 1957. This drive consisted of distributing
Clinistix mounted on a card with space for appropriate
data to be recorded by the person testing himself. De-
spite the fact that over 5,000 test envelopes were dis-
tributed primarily throughout the churches in Grand
Forks, only 461 tests were returned, indicating consid-
erable apathy on the part of the public in performing
this extremely simple test. Of the 461 tests, there were
93 individuals who reported a family history of dia-
betes, 344 negative tests without positive family history
of diabetes, and 24 positive tests were found in the entire
testing program. Of these 24 tests, follow-up data has
not yet been completed, but preliminary estimates indi-
cate that at least 1 new case of diabetes was discovered.

The results of the drive in Grand Forks indicate that
regardless of how simple and convenient one makes the
self-testing device, public response apparently depends
primarily upon the amount of publicity and inducement
offered to take advantage of the test. In direct contrast
to this meager response is the fact that some 7,000 urine
specimens were returned when 9,000 containers were
distributed in Grand Forks by the Jaycees from house
to house several years ago. Despite the inconvenience
of this method, it yielded the most rewarding results to
date, and many new cases of diabetes were discovered
as a result.

In summary, it would seem that the public health
aspect of the magnitude of the diabetes problem should
be stressed with wide publicity via the press, radio, and
through local organizations if adequate results are to be
obtained from detection drives. There was little or no
publicity given to the 1957 Grand Forks drive, and the
results depended entirely upon the individual’s interest
in reading directions on the envelope and in mailing the
results of his test to his personal physician or the Grand
Forks District Medical Society. While Clinistix is an ex-
cellent and highly convenient testing device, it will not
be the answer to successful diabetes detection drives
unless an effective publicity program is properly exe-
cuted.

E. A. Haunz, M.D., Chairman

Committee on Foreign Trained Physicians

The number of foreign trained physicians seeking
licensure in the United States began to increase about
1936, and, by 1940, over 3 times as many were exam-
ined as in 1936. Beginning in 1944, the number de-
creased until 1951, when there was a noticeable in-
crease, and in each succeeding year since there has been
a substantial increase. In the period 1946-1956, 8,828
graduates of foreign medical schools were licensed in
the United States and over half of these were licensed
in 3 states — New York, Illinois, and Ohio. The failure
rate in these 3 states was high; namely, 59 per cent,
70 per cent, and 29 per cent. Grand ten-year failure
rate in all states was 47 per cent as compared with a
failure rate of around 3/2 per cent for United States and

Canadian graduates. It is difficult to state how many
foreign graduates in the United States are not licensed,
but it surely must be somewhere in the 7,000 to 10,000
figure.

There are over 500 medical schools in countries out-
side the United States and Canada. In 1950, the A.M.A.
listed some 50 of these schools as appearing to have the
same curriculum as United States schools, and gradu-
ates of these schools were recommended for favorable
consideration by United States examining boards. The
balance of the foreign schools were neither approved or
disapproved. Since there is no possible way to survey
and appraise these schools, the Council of Medical Edu-
cation of the A.M.A. has decided to discontinue such list-
ings after 1959. Such a decision is surely a wise one
as the list was of no possible value and only caused
confusion to both the examining boards and foreign
physicians. In general, foreign graduates are not eligible
for licensure in 10 states; 21 states accept only graduates
of the list previously published by the A.M.A., a few
states have developed their own list of acceptable
schools; 28 states require one year of internship in the
United States; 21 states require full citizenship; and 15
Boards require declaration of intent.

After four years of study and preparation, the Edu-
cational Council for foreign medical graduates has been
established under the sponsorship of the Federation of
State Boards, the Medical Council of the A.M.A., the
Association of American Medical Colleges, and the
American Hospital Association. This organization will
study and interpret credentials and conduct examina-
tions in the United States several times a year to deter-
mine if the applicant possesses the same quantity and
quality of medical education and knowledge as the Amer-
ican graduate. Several states, and North Dakota is one,
will accept a certificate from this council as evidence of
sufficient medical knowledge to admit him to the state
board examinations. It is hoped that more states will
make use of this certifying agency.

In 1948, Congress passed the United States Exchange
Act, the purpose of which was to promote international
exchange of knowledge and skills and to promote inter-
national good will and understanding with nations who
were friendlv with the United States. This act was re-
vised in 1952 and again in 1957.

It has been most difficult for vour committee to obtain
figures indicating the extent of this exchange program
from the Department of State, under which it operates.
In 1956, 18,995 professional, technical, and kindred
workers were admitted to the United States, but any
breakdown of this figure to show how many were phy-
sicians could not he obtained.

In the same year, 3,452 of this group departed from
the United States. Approximatelv the same ratio exists
for the past five years, so probably about 80 per cent
of this group remains in the United States. The following
figures have recently been obtained from the Institute
of International Education and are assumed to be ap-
proximately correct:

In 1954 and 1955, foreign physicians on exchange
program numbered 4,813, of whom 1,709 were interns
and 3,104 were residents.

In 1955 and 1956, foreign physicians on exchange
program numbered 6,167, of whom 2,343 were interns
and 3,824 were residents.

In 1956 and 1957, foreign physicians on exchange
program numbered 6,741, of whom 1,988 were interns
and 4,753 were residents.

No information could be obtained as to how many
returned to their native land.

394

THE JOURNAL-LANCET

There are about 7,000 graduates from our 84 United
States medical schools each year. The average number
of medical students in each class in the United States
and Canadian medical schools is under 100. Three
United States schools have over 100 students in each
class; enrollment in each class in foreign medical schools
reached into the hundreds and, in some cases, 1,000 to
2,000. One can easily see from such figures that any
personal contact between faculty and students is impos-
sible. There are over 12,000 approved internships and
25,000 approved residencies among about 1,000 hospi-
tals sponsoring such. These figures show that not enough
physicians graduate in the United States each year to
fill these internships and residencies. Naturally, one must
ask, “Are we graduating too few doctors in the United
States or have we too many approved internships and
residencies?” This question is frequently discussed in
deliberations of these organizations, which are interested
in the problem. Last year there were 6,741 interns and
residents on the staff of 794 hospitals in 44 states who
were graduates of foreign medical schools. Many of
these physicians are not licensed in any state.

There are about 500 foreign students enrolled in
United States medical colleges and about 12,000 United
States citizens enrolled in foreign medical schools, most
of whom are in Switzerland and Italy. There must be
some special reason for this, as last year vacancies were
available in most United States medical schools for well-
qualified students seeking admission.

The foreign physicians in the United States for med-
ical training on student visas are morally bound to
return to their native land after three years of study in
order that by means of this training, the standards of
medical care can be improved in those countries. How
many actually return appears to be restricted informa-
tion; at least all such inquiries directed by your chair-
man to the State Department have been ignored. It
would seem that after one year of residence in the
United States, foreign students are not anxious to go
home; after two years, they are very reluctant; and after
three or more years, they are determined not to return
and will utilize every possible means to prolong their
stay here. While Congress stated on June 4, 1956, that
an exchange visa cannot be changed into an immigrant
visa until at least two years after departure from the
United States, there are numerous ways to evade this
restriction. At present, many of these doctors complete
a three-year residency in some specialty, and, if unable
to remain in the United States on an immigrant visa,
they simply change to some other specialty in order to
continue to reside in the United States for further train-
ing.

If international understanding is to be served and
world medical standards are to be raised, it is desirable
and essential that the American trained foreign physician
return to his own country and put his training into use.
It is well to keep in mind that when we remove quali-
fied physicians from countries which already lack suffi-
cient physicians, such as India, Turkey, Greece, and the
Middle East and Africa, we defeat the very purpose of
the Congressional Act. In President Eisenhower’s mes-
sage to the Senate on July 1, 1955, he stated: “All the
exchange programs are founded in good faith. We can
maintain them as effective instruments for promoting
international understanding and good will onlv if we
insist the participants honor their commitments to ob-
serve the conditions of the exchange. Exchange aliens
must return to the country from which they came to the
United States, and the United States must not permit

cither immediate re-entry or other evasion of the return
rule.”

No examining board has the wish to interfere with
any provisions of the Immigration Act. However, wc
are obligated to insist that physicians coming to this
country be fully evaluated on the basis of our medical
standards before being granted the right to practice
medicine.

It is the official duty of all state examining boards to
accept the qualified physicians and to reject those who
are not qualified, so that the American people will con-
tinue to receive the high type of medical service they
are entitled to.

Foreign physicians in North Dakota. In the period
1950 and 1952, 15 displaced foreign physicians were
eacli given a temporary license in North Dakota after
serving at least one year as an intern in a North Dakota
Hospital and writing the state board examinations. Two
social agencies placed these physicians where it ap-
peared medical attention was insufficient, and, in some
cases, they were given financial assistance by these com-
munities. Of these men, 8 still remain in their original
location, 5 have left the state, and 2 have moved to
other communities in North Dakota. Thirteen of these
men have obtained permanent licenses.

During the 1949 to 1958 period, 17 foreign physicians
were licensed in North Dakota, and 12 foreign physi-
cians failed the state board examinations. Of the 17
licensed, 5 have left the state.

As secretary of the North Dakota State Board of
Medical Examiners, your chairman receives hundreds of
letters yearly (several in each day’s mail) requesting
information as to how to obtain a license in North Da-
kota. Most of these requests come from foreign physi-
cians who are not licensed in any state and who are
either in internships or residencies or are salaried physi-
cians in some state mental or tuberculosis hospital.

Many are from substandard schools and have been
refused entrance to many state board examinations or
have failed before various boards. It is hoped that ex-
amining boards in the United States will consider cer-
tification by the Educational Council as comparable to
graduates from approved medical schools in the United
States and Canada. The purpose of the Educational
Council is not to exclude the foreign graduate, but it
will surely fail in its purpose if it does not exclude the
foreign graduate who does not meet our high standards
of medical education.

“MEDICAL STATUTES— Chapter 43-17— Physicians
and Surgeons, 43-1722. License; Fees. An applicant
for a license to practice medicine, found by the board
to be qualified for licensure, shall be granted a license
to practice medicine in this state; provided, however,
that, if the applicant is not at the time a citizen of the
United States, he shall be granted only a temporary
license, valid for not to exceed six years, such license to
be converted by the board into a permanent license only
upon his acquiring full United States citizenship before
the expiration of such period and onlv if, during the
entire period from the issuance of such license to the
acquisition of citizenship, he shall have practiced the
profession of medicine continuously within this state,
otherwise to terminate upon the expiration date of such
temporary license. The license shall be signed by the
president, the secretary-treasurer, and members of the
board, and shall have the seal of the board affixed
thereto or impressed thereon. The fee for the examina-
tion shall be determined bv regulation of the board.

Source: R. C. 1943; am’d. S.L. 1957, c. 302, s. 10.”

C. J. Glaspel, M.D., Chairman

SEPTEMBER 1958 395

Committee on Emergency Medical Service

Progress has been made in setting up a civil defense
plan in North Dakota. A preliminary operational sur-
vival plan is in print as of November, 1957.

The State Health and Medical Care Service will have
the following organization and duties:

A. Chief of Health and Medical Care (director of
Public Health, State Health Department) will:

1. Coordinate and direct operations of all divisions of
Health and Medical Care Service.

2. Coordinate planning and operations of the service
with those of other civil defense agencies.

3. Coordinate planning and operations of the service
with the American Red Cross and other private
or public agencies having civil defense health re-
sponsibilities.

4. Choose his deputy and subordinates in the scheme
of the service’s organization and make provision for
a line of succession in the organization.

B. Deputy chief of Health and Medical Care ( di-
rector, Division of Preventable Diseases, State Health
Department) will assist the chief of the health and med-
ical Care Service in the discharge of his responsibilities
and act as chief in the absence or incapacity of the chief.

C. Chief of the Medical Care Division (director, Di-
vision of Maternal and Child Health, State Health De-
partment) will coordinate all medical care activities and
all medical care facilities and their equipment.

D. Deput\j chief for Hospital Facilities (director, Di-
vision of Hospitals, State Health Department), will co-
ordinate the establishment and operation of all hospital
facilities.

E. Deputy chief for Medical Personnel (executive sec-
retary, North Dakota Medical Association) will coordi-
nate the selection and allocation of medical personnel.

F. Deputy chief for Paramedical Personnel (director,
Division of Nursing, State Health Department) will co-
ordinate the selection and allocation of all paramedical
and lay personnel assigned health and care duties.

G. Deputy chief for Inpatient Care (president. North
Dakota State Medical Association) will coordinate the
policies for treatment of all patients requiring hospi-
talization.

H. Deputy chief for Outpatient Care (president-elect.
North Dakota State Medical Association ) will coordinate
operations and policies for treatment of all outpatient
cases.

I. Chief of the Blood Program (director of State
Blood Bank) will coordinate and direct the procurement,
collection, processing, storage and maintenance of in-
ventories, and the distribution of blood and blood sub-
stitutes.

|. Chief of the Biological and Chemical Warfare Di-
vision (chief of Laboratory Services, State Health De-
partment ) will coordinate and direct all operations per-
taining to detection, protection, and treatment of chem-
ical and biological warfare agents and their effects.

K. Deputy chief for Biological and Chemical War-
fare— Human Branch (director of Grand Forks Public
Health Laboratories) will coordinate and direct all op-
erations regarding defense against chemical and bio-
logical agents affecting humans.

L. Deputy chief for Biological and Chemical War-
fare— Food Plants and Animals Branch (director of Bis-
marck Public Health Laboratory, State Health Depart-
ment ) will coordinate and direct all operations regard-
ing defense against chemical and biological agents af-
fecting food plants and animals.

M. Chief of Public Health (director, Division of Gen-

eral Sanitation, State 1 lealth Department ) will coordi-
nate and direct all operations pertaining to the protec-
tion of the environment and the health of the public.

N. Deputy Chief of the Water Supply Section (di-
rector, Division of Water Supply and Pollution Control,
State Health Department) will coordinate and direct all
operations for insuring the purity for human consump-
tion of water sources and supplies.

O. Deputy Chief of Food and Milk Section (chief,
Sanitation, Bismarck City Health Department) will co-
ordinate and direct all operations for insuring the purity
for human consumption of food and milk.

P. Deputy Chief of Sewage and Waste Disposal Sec-
tion ( assistant director, Division of Water Supply and
Pollution Control) will coordinate and direct the dis-
posal of waste and sewage.

0. Deputy Chief of Insect and Rodent Control Sec-
tion (director, Division General Sanitation) will coordi-
nate and direct all operations to minimize the effects of
insects and rodents on humans, plants, and animals.

R. Deputy Chief of Radiological Warfare Effects Con-
trol (director, Division of Institutional Sanitation-SHD )
will coordinate and direct, in liaison with the Radio-
logical Defense Service, operations to counteract the ef-
fects of radioactivity on humans, plants, and animals.

S. Mortuary section ( president, State Board Embalm-
ers) will coordinate and direct the planning and opera-
tions to include: (a) the proper and efficient disposal of
human remains and ( b ) the maintenance of complete
legal records concerning such disposal, including the dis-
position of personal property of deceased persons.

T. Service .staff

1. Supply officer (director, Division of Dental Health,
State Health Department) will maintain inventories
of medical supplies and coordinate and transmit to
the Supply Service, via CD command channels, re-
quests for additional medical supplies.

2. Transportation officer (director. Division Adminis-
tration State Health Department) will maintain
records of transportation sources available to the
Health and Medical Care Service and coordinate
and transmit to the Transportation Service, via CD
command channels, requests for additional trans-
portation facilities.

3. Communications officer (Communicable Disease
Investigators, SHD) will direct the operation of
communication media assigned to the Health and
Medical Care Service and coordinate and transmit
to the Communications Service, via CD command
channels, requests for use of additional or substi-
tute media.

4. Liaison staff officers will, as determined necessary,
coordinate the operations of the service with those
of other CD ageneies, other government agencies,
and special public, quasi-public, and private agen-
cies, such as the Red Cross and the Salvation Army.

R. F. Nuessle, M.D., Chairman

Committee on American Medical Education
Foundation

North Dakota dropped about $500 in the 1957 contri-
butions to A.M.E.F. as compared with 1956, yet the
same number contributed, and, in scanning the names
of the contributors, it is about the same group that eon-
tributes each year. I am sure each and every one is de-
sirous of earning his own share, and I am inclined to
feel that the fault lies in lack of district organization.
Our intentions may be good but unless someone in
each organization makes personal contacts, the donation
is not made.

396

THE JOURNAL-LANCET

In the American way, each state has adopted a dif-
ferent attack to the problem. Illinois was the first to
declare that this should be the responsibility of every
member of the society and, therefore, passed a dues in-
crease of $20 a year per member allocated to the
A.M.E.F. In 1955, California, Idaho, Nevada, and Ari-
zona also raised their dues for the same purpose. These
generous contributions from the societies themselves are
matched in many states bv purely voluntary appeals
done in an organized way at the local level. By this
method, Minnesota last year donated $36,846. In Penn-
sylvania, the House of Delegates voted in favor of a
$25 voluntary contribution by each member — such a con-
tribution to A.M.E.F., unearmarked, resulted in a match-
ing gift from the Ford Foundation. Probably needed
stimulus might be provided if our House of Delegates
would place their stamp of approval on each member
of our state society making such a voluntary gift.

W. E. G. Lancaster, M.D., Chairman

Committee on Cancer

Your chairman attended 7 cancer meetings during the
past year, 3 national and 4 state. The annual session
of the American Cancer Society was held in New York,
November 1, 1957. At the scientific session, papers on
“Cancer of the Head and Neck” were thoroughly dis-
cussed by eminent surgeons. The first impression left
one feeling that the surgery was extremely radical, but
after witnessing five- and ten-year survivals and perma-
nent cures without much disfigurement, such type of
surgery seemed definitely justified. Dr. Hayes Martin,
chief of the Head and Neck Service at Memorial Hos-
pital, New York, gave an amazing report on approxi-
mately 1,100 cases of cancer of the head and neck. It
was surprising to note that many of the single lesions
of the tongue without nodal involvement only received
excision of the primary tongue lesion, whereas other
surgeons definitely argue for a neck dissection. The busi-
ness session at this meeting was concerned primarily
with the national policy on fund raising. The independ-
ent fund raising and educational crusade has been an
essential part and a major factor in the immense growth
of cancer research and an increase in the number of lives
saved from cancer each year. A resolution was adopted
at this meeting to have all states withdraw from the
United Fund Raising Campaigns after 1960. This prob-
ably will be unpopular with the public at first, but when
they realize that our research program must continue
if we are to find the cure for cancer, and the only way
to continue this policy is to continue our independent
fund raising method, they will accept this policy.

Your chairman is a member of the National Scientific
Committee and also a member of the National Public
Information Committee. A meeting of both committees
was held in New York, January 16, 1958. A variety of
policies were presented and adopted for lay education
and also scientific education. I had the pleasure of view-
ing at this meeting some movies of an interview the
American Cancer Society conducted with Dr. Hocksey
of Texas. I am hoping to bring these 2 reels of movies
to North Dakota to exhibit at the various medical so-
cieties in the future. They are very interesting and amus-
ing. After having seen these movies, our North Dakota
doctors will be better acquainted with the problems we
have in combating the work of quacks.

A division meeting of the northwestern states of the
American Cancer Society was held in Butte, Montana,
September 10, 1957, at which time your chairman was
accompanied by Dr. Rodgers, of Dickinson, and Dr. O.

W. Johnson, of Rugby. At this meeting, a thorough dis-
cussion of cytology, in addition to other business matters,
was brought to the attention of the participants. We
are again confronted with the problem of developing cy-
totechnologists. Pathologists appear overburdened with
cytologic examinations and, until this bottleneck is cor-
rected, the problem remains immense.

You will recall that last year we stated that a pro-
gram had been decided upon to establish cancer regis-
tries in all North Dakota hospitals. An inquiry was sent
to all staff members and the chairmen of the staffs to
indicate whether they would approve or disapprove of
the establishment of such a registry. We arc very happy
to report that of all the hospitals in North Dakota, only
2 rejected our proposal. There already were 4 very fine
cancer registries established in North Dakota, and to-
date we have established 14 new additional cancer
registries in North Dakota. There are approximately 70
hospitals in North Dakota, and, at this rate, we hope
to complete our program within four more years. The
North Dakota Medical Librarians will have their an-
nual meeting at Fargo, April 22, 1958. At this time,
we will have a speaker from the American Cancer So-
ciety office of New York, Dr. Aubry Schneider, who will
give a thorough discussion of the cancer registry, its
purpose, and how to establish it. We also hope to have
the chief of staff from each hospital keep a watchful eye
on these registries and push them along from time to
time. We are informed that in the not too distant future
a cancer registry will be a requirement for hospital
accreditation.

In spite of the late cancellation of a prominent dental
pathologist, we were able to present 3 outstanding
speakers for the 1958 Cancer Caravan. The subject of
“Cancer of the Head and Neck” was chosen as the
theme for 1958. This theme served as a double purpose.
In the past, we felt that we had badly neglected our
dental friends in our cancer work. Your chairman ap-
peared at the state dental meeting in Fargo, in June
1957, at which time he offered to invite the dentists to
cooperate in our cancer program. The dental society
appointed Dr. Russell Sands, of Fargo, and Dr. V. A.
Corbett, of Minot, as their representatives to our scien-
tific committee. Following this appointment, it was de-
cided to procure a medical and dental team to present
our 1958 Caravan. These meetings began in Williston,
March 18, 1958, at which time Dr. R. E. ReMine, sur-
geon, and Dr. James Masson, a plastic surgeon of the
Mayo Clinic, were our principal speakers. A very good
program and lecture with slides on “Cancer of the Head
and Cancer of the Neck” were presented. This group
also presented similar lectures in Dickinson, Jamestown,
and Bismarck. The dental profession was well represent-
ed at these meetings. The second section of our pro-
gram began in Fargo on March 25, 1958, at which time
Dr. Stuart Arhelger, associate professor of surgery at the
University of Minnesota and director of its Tumor Clinic,
presented a paper on “Cancer of the Oral Cavity.” It
was on this program that the additional paper on “Soft
Tissue Lesions of the Oral Cavity,” which was cancelled,
was to have been presented, but Dr. Arhelger very ably
upheld the high standards of cancer lectures. This pro-
gram was also presented at Grand Forks, Devils Lake,
and Minot. It becomes increasingly difficult to procure
speakers wbo are willing to be away from their work
for five or six days, and we are giving considerable
thought to the idea of having each society choose its
own speaker for the spring of 1959. This would neces-
sitate a speaker spending only one or two days away

SEPTEMBER 1958

397

from home. Each society will be contacted early this
fall for its opinion of this idea.

During the past year, the North Dakota unit of the
American Cancer Society has continued the policy of
presenting cancer speakers to other organizations in the
state. A cancer speaker was furnished for the 1957 state
meeting, and a similar speaker will he furnished for the
1958 state meeting at Minot in May. Additional cancer
speakers were furnished for the obstetric and gynecologic
meeting in Dickinson during the fall of 1957 and also at
the North Dakota State Surgical Society meeting in
Grand Forks in 1957. We hope to continue this policy
as we feel it is more satisfactory when the choice is
made by the individual organization. We also plan to
furnish a speaker tor the State Dental Convention in
Bismarck in June 1958. A recent communication from
the dental secretary reveals that, to-date, Dr. Kling, of
the Quain and Ramstad Clinic, will present a lecture on
“Cancer of the Oral Cavity” to the dentists at their
state meeting.

A rather feeble attempt was made to investigate ru-
mors of a quack operating in the Underwood, North
Dakota, area. Dr. O. R. Bjornlie, a naturopath, was
found to be operating a thriving practice in a residen-
tial home in Underwood. Several cars were parked on
the outside and, upon entering the living room, 12 peo-
ple were found waiting patiently for the services of Dr.
Bjornlie. After waiting for thirty minutes, your investi-
gator left without being able to interview this practi-
tioner. Communications to the attorney general reveal
that this office has no information on this man and that
there is no provision in the statutes for licensing a per-
son to practice in naturopathy. Communications with
Dr. Hochhauser, of Garrison; Dr. Anderson, of Under-
wood; and Dr. Glaspel, secretary of the State Board of
Medical Examiners, reveal that attempts are being made
to obtain testimony from disgruntled patients who
would be willing to appear and testify in court. Only
by this method woidd we be able to present a sound
case and eradicate this quack.

Doctors are again encouraged to cooperate with their
local county commanders of the North Dakota Cancer
Society by being available as speakers at city and
country cancer meetings throughout the year. We have
a very fine Speaker’s Handbook available at our home
office in Fargo. These speeches require no previous
preparation, may be easily read, and require only ten
or fifteen minutes to present. The presence of an M.D.
at a cancer meeting enhances the program and adds
considerable weight to the authenticity of statements
made by lay speakers. Doctors are also urged to re-
member that we have several Kinescopes on cancer of
various areas of the body available for district meetings
and also hospital staff meetings. As you know, these are
very fine films covering a variety of cancer topics, and
are available upon request from our home office in
Fargo.

Please do not forget to report your cancer cases.

C. M. Lund, M.D., Chairman

Committee on Geriatrics and Rehabilitation

A meeting of this committee was held in Fargo,
December 13, 1957, at the Gardner Hotel. Present were:
Dr. Paul Johnson, of Bismarck; Dr. H. C. Walker, of
Williston; Dr. Lee Christoferson, of Fargo; Dr. Robert
Rodgers, president of the state society; Mr. Lyle Limond,
executive secretary of the state society; William E. Unti,
executive director of the North Dakota chapter of the
Society for Crippled Children and Adults; Miss Frances

Landon, executive director of the Rehabilitation Unit
of the North Dakota State Medical Center; and Dr. T.
H. Harwood, chairman.

The meeting was called to order at 7:45 p.m. Dr.
Harwood and Miss Landon presented the picture of the
current status of the Rehabilitation Unit. The physical
plan of the Unit is almost completely finished, and
equipment is being moved in. Staff members have been
appointed, including a secretary, a physical therapist,
an occupational therapist, a counseling psychologist, and
a prevocational advisor. A social worker will join the
staff earlv in January. A speech and hearing therapist is
still being considered.

It was pointed out that the Unit is to be an outpatient
facility and that patients will have to be housed nearby
and transported daily to the Unit for treatment.

Operating plans at the present time do not provide for
a physiatrist on the staff. This is because it is felt that
it is very important for the referring physician to be part
of the rehabilitation team in actuality as well as theo-
retically. When a physician refers a patient, as all pa-
tients will be referred directly or indirectly, the physi-
cian writes orders for the therapies which the patient
is to receive. In this way, a close relationship is estab-
lished with the referring physician. In some areas,
problems have arisen when the physiatrist in charge
tends to take over the complete care of the patient, as
the referring physician feels that he has lost his patient
to someone else.

It was also pointed out that the Medical Center Ad-
isory Board has asked that the Committee on Geriatrics
and Rehabilitation be the official medical advisory com-
mittee on policies regarding doctor-unit relationships.

In the course of the discussion, the following points
were brought out:

1. Both evaluation of the patient’s situation and treat-
ment would be undertaken. There are many programs
in the state in which it is necessary to determine whether
a patient is totally and permanently disabled. Such an
evaluation coidd be done at the Rehabilitation Unit.
On the other hand, a person might be in need of actual
treatment and would, in this case, receive treatment at
the Unit.

2. Dr. Rodgers asked how many physicians are quali-
fied to write prescriptions. This point was discussed at
some length. Dr. Christoferson felt that he would like
to be able to turn his patients over completely to an
M.D., have the therapy and management in his hands,
and then have the patient back with a report. Dr.
Rodgers agreed with this philosophy as did Dr. Walker.

3. Dr. Jensen mentioned that traumatic paraplegics
were a big problem in this area as well as in other parts
of the country.

4. It was asked what would happen if a patient were
referred to the Unit who had no local doctor in charge
of his case. It was stated that every effort would be
made to find a physician for him who could take charge
of his case and refer him as his patient rather than have
the individual come to the Unit without a doctor.

5. Dr. Christoferson pointed out that there is a defi-
nite gap between the Division of Vocational Rehabilita-
tion and re-employment. This point was generally agreed
upon, and it was felt that efforts should be made to
bridge this gap. Mr. Unti suggested that employment
services should take over at this point.

6. Dr. Walker asked about consultations which might
be necessarv while the patient was under treatment at
the center. Who would call for such consultations? At
present, in case a consultation is required, the referring

398

THE JOURNAL-LANCET

physician would be contacted and this matter discussed
with him so that a consultant of his choosing would be
called.

7. The question of referral was brought up again. It
was pointed out that we would be working with the
Division of Vocational Rehabilitation and with other
agencies in the state. Some of these agencies need Re-
habilitation Unit services in the course of their programs.
In some cases, since it is handling the case, details of
referral would be handled by the agency. In each case,
however, the agency is already working with the doctor
in charge of the patient, and this relationship would
continue even though the agency is making the arrange-
ments. The Polio Foundation, Easter Seal Society, Work-
men’s Compensation, insurance companies, and others
might be the agency involved. It was pointed out that
every effort will be made to have services paid for by
the individual or by an agency. In case all efforts to
obtain payment fail, it was felt that the treatment would
not be withheld from a North Dakota resident for lack
of funds.

8. The question of referrals from allied medical
groups, such as osteopaths and chiropractors, was dis-
cussed. The general feeling was that we should work
with osteopaths. It was further felt that satisfactory
relations with chiropractors would be very difficult to
establish.

T. H. Harwood, M.D., Chairman
Committee on Maternal and Child Welfare

The Maternal and Child Welfare Committee of the
State Medical Association met in Jamestown on Decem-
ber 12, 1957, and again in Fargo on March 19, 1958.

The committee submits the following for your recom-
mendation :

1. We recommend that the local county medical so-
cieties have periodic polio injections at least every two
years.

2. We recommend that a booklet be prepared for all
hospitals in North Dakota regarding the proper setup
for the care of newborn and premature infants and
delivery rooms.

3. We recommend that the outline which is prepared
at present by the State Health Department regarding
immunizations be brought up-to-date and a copy for-
warded to all doctors in the state.

4. The committee feels at present that the best eye
prophylaxis is the instillation of silver nitrate. It is safe
not to irrigate. If irrigation is done, it should be carried
out fifteen minutes after the initial instillation of silver
nitrate using distilled water.

5. We do not recommend the use of intramuscular
penicillin as an eye prophylaxis.

6. We recommend that all hospitals in the state do
perinatal mortality studies with a view to lowering the
neonatal mortality.

7. We recommend a review of the adoption laws for
North Dakota.

8. The committee submits the following minimal re-
quirements for the filing of adoption papers:

1. History and physical examination of husband.

a. Sperm count.

1. Number per cc.

2. Motility.

3. Per cent of abnormal form.

b. If substandard, at least 2 more counts.

2. Historv and physical examination of wife, including

pelvic examination.

a. Thyroid evaluation.

b. Temperature chart — minimum of three months.

c. Endometrial biopsy.

d. Determination of tubal patency by Rubin’s test
or utcrosalpingogram.

Cervical factor by Huhner test at midcycle.

3. Is the physician aware of any psychologic factors
that would impair fertility?

Note. If absolute sterility found in the male, it is not
necessary to give the wife a complete examination.

Robert E. Lucy, M.D., Chairman

Committee on Crippled Children

The meeting of the Committee on Crippled Children
was held at the Gardner Hotel, Fargo, December 14,
1957, and was called to order at 9:40 a.m. by the chair-
man, Dr. P. L. Johnson. Members present were: Drs.
P. L. Johnson, chairman, A. E. Culmer, Jr., D. T. Lind-
say, C. W. Plogan, L. B. Silverman, O. V. Lindelow,
R. D. Nierling, and |. C. Swanson. Others present were:
Mr. Carlyle O. Onsrud, executive secretary, Public Wel-
fare Board; Mr. William E. Unti, executive director,
North Dakota Society for Crippled Children and Adults;
and Mr. Lyle A. Limond, executive Secretary, North
Dakota State Medical Association.

The chairman opened the meeting by discussing a
letter sent out by the Crippled Children’s Services and
signed by himself on December 20, 1956. This letter
contained extension of Crippled Children’s Services to
include 14 conditions which were previously not covered
but for which various counties had requested relief be-
cause of financial difficulties, of which the named 14
had been accepted by Crippled Children’s Services.
Reference was also made to the resolution passed by the
Devils Lake District Medical Society criticizing this ex-
panded program as well as our various discussions of
the association’s House of Delegates as found on page
355 of the October 1957 issue of The Journal-Lancet.

The various members of the committee deliberated
about the resolution as well as the changes in the Crip-
pled Children’s program. It was felt that the aforemen-
tioned letter of December 20, 1956, failed to adequately
clarify the degree of continued participation by the local
physician in these varied Crippled Children’s cases. It
was also urged by Dr. Culmer that a previously planned,
but not carried out, personal visit by Dr. Icenogle to the
Lake Region District Medical Society and to other so-
cieties as well should be completed in an effort to fur-
ther clarify the Crippled Children’s program.

Dr. Lindsay stated that he felt that the medical di-
rector of the Crippled Children’s Services should screen
all applications for Crippled Children’s Services and that
also the case load should be carefully reviewed in an
attempt to overcome possible shortcomings, such as ac-
ceptance of ineligible people who could well afford to
pay for private care either on an insurance basis or as
a personal responsibility. He also felt there should be
a closer working relationship between the Crippled Chil-
dren’s Services and the referring physician so that the
physician can continue to take an active part and be
remunerated for his participation in the continued care
of the patient.

Dr. Nierling asked if it had been considered whether
Fellows of the American College of Surgeons should be
eligible to perform surgery under the Crippled Chil-
dren’s program. It was felt that the present require-
ments for participation shotdd remain intact, namely,
that only board physicians and surgeons are authorized
as consulting and operating surgeons. Any other quali-
fications would require arbitrary decisions for which
possible injustices would result.

Dr. Silverman opened the discussion regarding the

SEPTEMBER 1958

399

list of medical conditions included in the extended pro-
gram of the Crippled Children’s Services, and these
were discussed individually. He felt that celiac disease
should be eliminated and that probably rheumatoid ar-
thritis should also be eliminated except for the specific
treatment of various joint deformities. These decisions
were concurred in by the majority, and it was recom-
mended that they be eliminated from the list of the ac-
ceptable conditions.

Dr. Lindelow stated that he felt that any of the con-
ditions qualifying for Crippled Children’s Services should
be checked at least once by a specialist who can then
assume responsibility for accuracy in diagnosis and that
then much of the follow-up care could be carried out by
the referring physician.

Dr. Lindsay suggested that an information packet be
given all newly licensed physicians in North Dakota to
include information regarding Crippled Children’s Serv-
ices, other state agencies of the Public Welfare Board,
and other agents as well as other private agencies, such
as Blue Cross and Blue Shield.

Dr. Lindsay further commented as follows regarding
the Crippled Children’s Services program:

1. Greater stress should be placed on the continued
participation by the referring physician.

2. The consultant’s part in the program should be
reduced to the minimum consistent with good care for
the child.

3. The Crippled Children’s program should be as
selective as possible, accepting only eligible new cases,
and old cases, which can be financed privately, should
be removed from the program.

4. There should be no change in out-of-state referrals,
and a specialist who would otherwise be eligible to care
for a certain condition should be the one to determine
whether a child can or cannot be adequately cared for
in the state before recommending out-of-state referral.

5. The varying participation by internists and pedia-
tricians treating crippled children with medical condi-
tions should continue to be interpreted rather loosely
and in accordance with local custom.

Mr. William E. Unti’s proposal and actions thereto :
Mr. Unti explained the purposes of the proposed Indus-
trial Workshop in Jamestown. He asked for this Com-
mittee’s opinion on this proposal.

Dr. J. C. Swanson moved that the committee approve
the proposal of an Industrial Workshop in Jamestown.
The motion was seconded by Dr. Lindsay and carried.

Dr. Culmer moved that the council approve the presi-
dent of the North Dakota State Medical Association ap-
pointing a small liaison committee to work with Mr.
Unti on the sheltered workshop proposal. Motion was
seconded by Dr. Silverman and carried.

Dr. Culmer moved that the committee recommend
that a demonstration of one hour be given at an annual
meeting in the field of the crippled child. Motion was
seconded by Dr. R. D. Nierling and carried.

Meeting adjourned at 12:30 p.m.

P. L. Johnson, M.D., Chairman

Committee on Nursing Education

As to the report for the committee on Nursing Educa-
tion, no formal meeting was called for the year 1957
and 1958 because no apparent business or activity de-
manded such action. Continued contact with the exec-
utive office of the North Dakota State Nurses’ Associa-
tion has been maintained.

The only suggestion from that office was that the
North Dakota State Medical Association donate to the
state scholarship plan that the Nurses’ Association has

adopted. Their funds have not been adequate to cover
all of the young ladies who are interested in the nursing
profession.

There were no further suggestions from either the
committee or the North Dakota State Nurses’ Association.

C. R. Montz, M.D., Chairman

Committee on Constitution and Bylaws

Herewith is a report of the chairman of the Committee
on Revision of the Constitution and Bylaws. In accord-
ance with procedures and directives of the House of
Delegates and the council at the 1957 annual session at
Fargo, revision of the Constitution and Bylaws has been
completed and as of the time of the 1958 annual session,
a copy of the Handbook has been mailed to each mem-
ber of the association.

It appears to the members of the committee that a
special committee on revision of the Constitution and
Bvlaws need not be appointed annually in the future
until such a need becomes apparent.

Robert B. Radl, M.D., Chairman

Advisory Committee to the Public Assistance Division
oi the State Welfare Board

Quain and Ramstad Clinic, Bismarck, March 22, 1958.
The meeting was convened at 7:50 p.m. by the chair-
man, Dr. E. T. Keller. Members present were: Dr. E.
T. Keller, chairman; Dr. E. J. Larson; and Dr. C. H.
Peters. Others present were: Dr. R. W. Rodgers, Mr.
Ralph Atkins, and Mr. L. A. Limond.

Mr. Atkins, director, Division of Public Assistance,
spoke on ways of reducing costs for public assistance
cases as follows:

a. Children should assume more responsibility in car-
ing for the old folks.

b. There should be a cut-off date for some drugs —
no refills unless expressly ordered by the physician after
the cut-off date. Examples of exceptions to this pro-
cedure would be for insulin and digitalis. Further study
is to be given to this proposal.

c. The possibility of instituting a flat rate for the
chronically ill patient in nursing homes and/or in hos-
pitals is to be studied.

It was tentatively agreed that any period longer than
twenty-four hours previous to surgery was to be con-
sidered medical and not preoperative.

It was also tentatively agreed that fourteen to twenty-
one days could be considered postoperative for the nor-
mal surgical procedures.

Many other ramifications of the over-all problem of
the public assistance program were discussed at length
by the members of this committee.

Meeting adjourned at 10:40 p.m.

E. T. Keller, M.D., Chairman

North Dakota Joint Commission for the Improvement
of the Care of the Patient

The major purpose of this commission is to stimulate,
implement, assist in, and sponsor activities which will
contribute to the care of the patient as may be mutually
satisfactory to the appointing organizations.

To achieve this objective, the commission performs
as a service agency to the parent organizations. It shall
be the intention of the commission to obtain a better
understanding of the problems and programs of all rep-
resented groups; to serve as a source of information on
trends within the programs of the participating organi-
zations; to explore the needs for and stimulate studies
in areas of patient care in which the organizations par-
ticipate; and to perform such functions and carry on

400

THE JOURNAL-LANCET

such activities contributing to the major objectives as
may be mutually satisfactory to the appointing organi-
zations and to the commission.

I have met with this group twice and find that the
committee is primarily made up of nurses and an occa-
sional hospital administrator. They have spent most of
their time talking about the development of the licensed
practical nurses’ program in North Dakota and some
time on the subject of increasing tbe training programs
for the University of North Dakota student nurses.

R. O. Saxvik, M.D., Representative

Liaison Officer to the North Dakota State
Dental Association

Your liaison officer met the secretary of the State
Dental Association and Mr. Earl Abrahamson in No-
vember. The background for this meeting was the den-
tists’ general dissatisfaction with the fee schedule of the
North Dakota High School Athletic League, of which
Mr. Abrahamson is secretary. The Dental Association
through their secretary, Dr. jack Pfister, requested your
liaison officer to sit in on the meeting with the feeling
that perhaps a combined effort could be made in at-
tempting to revise the current fee schedule of the league.
Mr. Abrahamson stated that though the insurance of the
league was not meant to be a total payment for injury,
he felt that the fee schedule should be revised and he
would be pleased to meet the medical and dental profes-
sions in such an effort. Your liaison officer reported this
to our state office and respectfully suggested that the
matter be given to the Medical Economics Committee
for action. I can report at this time that the Dental
Association has met the Athletic League and has ob-
tained substantial increases in tbeir fees.

The Dental Association has asked to express their
pleasure with the appointment of a liaison officer to their
society, and also they wish to express their sincere desire
to work hand in hand in all ways possible with the State
Medical Association in all problems of mutual interest.
They have expressed a particular desire to have a close
liaison during the coming legislative year.

David G. Jaehning, M.D., Liaison Officer

Report of Representative to the Governor's
State Health Planning Committee

The State Health Planning Committee held its usual
2 meetings in 1957. The first was held June 5 in Bis-
marck to consider the over-all basic policy and priority
principles to be used for 1958 in the state plan for con-
struction of hospital and medical facilities in which Hill-
Burton and related funds are to be used. The basic
policy is governed to a considerable extent by United
States Public Health Service regulations and recom-
mendations regarding general hospital bed needs per
population, the location of nearby hospital facilities, the
general need of an area for nursing home facilities, and
specialized hospital facilities in connection with already
existing hospitals.

In brief, tbe current general philosophy adopted by
this committee is that very few new hospital beds are
needed in North Dakota. There is need to modernize
and approve facilities in certain areas already having
hospitals and possibly to expand some existing facilities.

At the present time, nursing home facilities are greatly
needed in most areas of the state. A number are under
construction and in tbe planning stage. We are advised
that several hospitals in the state are taking nursing
home type patients at reduced rates, partly to fill a need
but also to augment their incomes.

On September 24, 1957, also at Bismarck, the meet-

ing of the committee was held to hear the applications
of numerous communities and groups for aid for general
hospital and nursing home construction, rehabilitation
facilities, and neuropsychiatric facilities. Recommenda-
tion was made to the State Health Council for Hill-
Burton and related funds to be used on a 46 per cent
federal and 54 per cent local basis for tbe following
projects :

1. A 50-bed general hospital to replace the existing
30-bed St. Aloysius Hospital at Harvey.

2. A 40-bed nursing home addition to the Lutheran
Home for the aged at Grand Forks.

3. A 55-bed nursing home addition to the Lutheran
Home for the aged at Minot.

4. The extension and addition of rehabilitation facili-
ties at the Jamestown Children’s School.

An extra meeting of the State Health Planning Com-
mittee together with the State Health Council was held
on January 16, 1958, also in the Capitol Building at
Bismarck. The purpose was to hear a well arranged pro-
gram presented by members of both groups and others,
covering such items as rural and urban population trends
in North Dakota in relation to hospital and related facil-
ity needs, hospital nursing home and domiciliary home
needs in North Dakota, present and future hospital
needs, staffing and operational problems of North Da-
kota hospitals, problems of providing medical services
to rural communities, and proposed means of meeting
the various problems under discussion.

This was an interesting and valuable meeting.

Your representative has been impressed with the gen-
eral intelligence and knowledge regarding health needs
of North Dakota by the committee members, by tbe
seriousness with which they undertake their duties, and
by the lack of political consideration evidenced in the
various discussions and decisions made. The work of
this committee would be much more pleasant if we had
enough Hill-Burton and related funds to allow funds
to be granted to all applicants, as the vast majority of
the requests for funds are for worthwhile community
projects. Such not being tbe case, the committee seri-
ously weighs all factors involved before making its rec-
ommendation to the State Health Council.

In the budget proposal to the present Congress, the
president has recommended a substantial reduction in
the Hill-Burton funds. Thus, unless Congress in this elec-
tion year does not follow the administration recommen-
dations, we can anticipate an appreciable reduction in
the amount of funds available from the federal govern-
ment for future projects.

Phillip H. Woutat, M.D., Representative

Committee on Medical Education

This committee had a meeting in Fargo on May 26,
1957. It will hold another meeting at 8:30 a.m.. May
4, 1958, in Minot.

At the meeting on May 26, various phases of the
medical school were discussed.

The possibility of tbe medical school arranging short
courses of one to three days’ duration was discussed.
It was felt that the medical school could put on some
short courses in the basic sciences, and that it would be
possible to include some clinical papers in these courses.
It was felt that it might be possible to bring in 1 or 2
outside speakers for some of these short continuation
courses.

The committee, therefore, recommended that Dean
Harwood try to arrange in the future to conduct some
continuation courses at the medical school.

SEPTEMBER 1958

401

In a letter of April 3, 1958, Dr. Harwood reports on
the medical school and its activities as follows:

“The School of Medicine received its annual contribu-
tion from the American Medical Education Foundation
in March this year. The contribution was $3,945. This
figure is down a bit from last year.

“Our student applicant problem is one of our most
serious ones. Last year, at the time of the report, it
seemed as though our applicants were in goodly num-
ber, but by the time school began, we had scarcely
enough students to fill our instate quota of 36. We do
not lack applicants actually in gross number, but we
do lack applicants who have grades equal to the Uni-
versity average. The School of Medicine has not yet
thought it wise to accept students below average scho-
lastic achievement in college work.

“Forty-one first-year students were admitted in Sep-
tember 1957. These consisted of 37 instate students and
4 out-of-state students. At the present time, we have
35 left. Two students withdrew and 4 failed, making a
total loss of 6, which in terms of percentage is well
above the national average.

“The Medical Center Loan Fund was used this year
by 22 third-year and 8 fourth-year students who bor-
rowed a total of $54,500 from this fund. In addition
to this, the entire amount of the Woman’s Auxiliary
Loan Fund was used, the amount requested by 12 stu-
dents being reduced from $600 to $500 so that it would
go around to all the individuals.

“The Rehabilitation Unit was completed in January
of this year and has been in operation since that time.
Our patient load has been light but is growing steadily.

“Plans for the construction of a tuberculosis hospital
at the University are still being discussed with many
pros and cons.

“Our graduating class of 36 last year all transferred
as follows: Bowman Gray — 3; Columbia — 1; Harvard —
2; Illinois — 1; Kansas — 1 1 ; Marquette — 1; McGill — 2;
Northwestern — 4; Pennsylvania — 4; Southwestern — -3;
Tufts — 1; Tulane — 1; and Washington — 1.

"It is our understanding that 5 of our graduates of

1956 are returning to North Dakota to intern this com-
ing July.”

You will note in Dr. Harwood’s letter that it is a
problem to obtain enough good student applicants. I
think the doctors in North Dakota could assist in this
problem if they would encourage good students inter-
ested in medicine to apply for admission to the North
Dakota Medical School.

II. M. Bekc:, M.D., Chairman

Report of the Representative to the Medical Center
Advisory Council

The Medical Center Advisory Council has held 2
meetings since the last report — June 15, 1957, and Jan-
uary 25, 1958 — both of which your representative at-
tended. The following are pertinent transactions.

1. The tuberculosis hospital. You will recall that the

1957 state legislature contemplated the construction of
a new tuberculosis hospital of approximately 100 beds
in connection with the Medical Center and instructed
the Medical Center to retain approximately $600,000 in
funds to aid the construction of this facility.

Under the auspices of the State Board of Administra-
tion, a recent survey of the state’s tuberculosis hospital
needs was made by Dr. Cedric Northrop, the State of
Washington Tuberculosis Control officer; and Dr. Robert
Davies, director of the State of Florida Tuberculosis
Board. These gentlemen appeared before the Medical

Center Advisory Council at the January 25 meeting
with a preliminary report of their impressions. While
their final report is not available, they feel that many
factors would make it unwise for us to construct a new
tuberculosis facility. The census at San Haven has been
reduced to 37 at the present time. Some of this reduc-
tion results from diverting Indian patients to a federal
facility in South Dakota. Some is also the result of
modern treatment methods, which reduce the hospitaliza-
tion period from a number of years to a few months.
It was brought out that since May, 1957, the hospitaliza-
tion needs for tuberculosis patients have been drastically
reduced. It was the preliminary impression of the sur-
veyors that it would be more advisable to contract for
hospital beds in another facility in the state and provide
for all the tuberculosis bed needs in that way. St. Mi-
chael’s Hospital in Grand Forks was reported to be pos-
sibly interested in such a plan. The final decision on this
matter, of course, is somewhat in the future, pending
the final report of the surveyors, action by the State
Board of Administration, and probably by the next legis-
lature.

2. Medical Center and University of North Dakota
Nursing program. Miss Margaret Heyse, director, Divi-
sion of Nursing, University of North Dakota, appeared
before the council with recommendations for expanding
the University’s Nursing School program. It is proposed
that the present educational program for providing nurs-
ing education on the University level be expanded with
the object of training more teaching and supervisory
nursing personnel. There appears to be a need for such
expansion, and it appears that the University Nursing
School should probably take the responsibility for such
a program. Accordingly, The Medical Center Advisory
Council recommended that such an expansion be insti-
tuted. One word of caution must be introduced. This
expansion appears to call for closing the present three-
year program in Deaconess Hospital, Grand Forks, and
using these facilities for training nurses in the expanded
four-year University program it the school is to be fully
approved. Your representative recalls some of the prob-
lems that have arisen in the state in the past due to
closing of three-year nursing schools in some of the
smaller hospitals and the present shortage of bedside
nurses, which appears to be statewide and is not im-
proving. Whether an expanded four-year program at the
University of Nortli Dakota would completely fill the
gap caused by abolishing the three-year program in
Deaconess Hospital is not clear, and it does not appear
to be advisable to abolish such a school until full re-
placement is available.

It is contemplated that by using other facilities in
North Dakota, such as the State Hospital at Jamestown
and the State School at Grafton, a four-year program
could be completely carried out within the confines of
the state. It is hoped that this will result in keeping
more graduate nurses within the state following gradua-
tion.

3. Rehabilitation program. The staff at the Rehabili-
tation Unit at the Medical Center has been functioning
since January 6, and the first patient was seen January
13. The staff is composed of Miss Frances Landon, di-
rector; a counseling psychologist, a physical therapist,
an occupational therapist, a social worker, and a prevoca-
tional supervisor as well as the usual office personnel.

Doctor Olmstead, a qualified physician in internal
medicine and on the teaching staff at the medical school
and the Student Health Service physician, is acting as
medical consultant for patients admitted.

As previously reported, the Rehabilitation Center in-

402

THE JOURNAL-LANCET

tends to take only patients referred lay a physician
and/or a state agency, such as the State Welfare Board.
A program of information for physicians around the
state is being undertaken.

It has been brought out that there may in the future
be need for housing facilities for patients spending any
length of time at the Rehabilitation Center for examina-
tion or treatment. It has been proposed that another
story be added to the Rehabilitation Unit to afford hous-
ing and kitchen facilities for adults and children during
such a period of stay.

The Medical Center does not have funds for such an
addition, so, if such becomes necessary, it would have
to be constructed somewhat in the future.

4. Biochemistry service. The use of the Biochemistry
Laboratories at the Medical Center by the physicians of
North Dakota for specialized tests has been increasing
rapidly and has become an expense necessitating the
addition of technical personnel, equipment, and chem-
icals. The load has reached such a point that the Med-
ical Center Advisory Council recommended that a fee
schedule be set up for biochemistry services and that
it be recommended to the Board of Higher Education
that a charge be made for these tests on a nonprofit
basis. We expect this to be instituted within the next
few months.

5. Medical Center loan fund. You will recall that the
1957 legislature directed that $75,000 of Medical Center
funds be made available each year for loans to medical
students to enable them to complete their education.
You will also recall that certain provisions were made to
encourage graduates to return and practice in the smaller
communities of North Dakota. To date, $53,000 of Med-
ical Center funds has been loaned to 19 juniors and 8
seniors. The medical school anticipates a similar amount
to be loaned again this year.

6. Psychiatric training program. To date, there have
been no applicants for this program.

7. Admissions. To date, there has been a total of 85
applicants for the freshman medical school class for the
fall of 1958. Fifty-one of these are North Dakota resi-
dents. It does not appear that the class of 40 students
will be filled with North Dakota residents, so some out-
of-state students will, no doubt, be accepted. As of
January 25, 1958, 21 North Dakota students have been
accepted.

There is no problem in transferring graduates to other
schools for their third and fourth year of training.

It might be pointed out here that, whereas a few years
ago two-year medical schools were being frowned upon
and discouraged to a considerable extent, there are in-
dications that attitudes are changing and that two-year
schools will receive more encouragement. Some four-
year schools have recently announced that they will be
able to give adequate training to more third- and fourth-
year medical students than they are able to take in their
first two-year classes, and it is apparently being recog-
nized in some places that the first two years of medical
school can adequately be taught in two-year schools,
probably at considerably less expense than in some of
the larger schools.

8. Postgraduate courses. A three-day postgraduate
course for doctors is being planned for November, 1958,
in cooperation with the Academy of General Practice of
North Dakota. This is contemplated to be a course cor-
relating the basic sciences with clinical medicine.

9. Cancer Research Laboratory. The Medical Center
has received a gift of $75,000 from Mrs. Bertha Ireland
of Grand Forks for a Cancer Research Laboratory. Fed-

eral matching funds of $75,000 have been obtained.
Plans are underway for a separate building for this
project, and grants have been obtained for stipends for
investigators. It is contemplated obtaining a full-time
established investigator to direct the work in this labora-
tory.

Phillip H. Woutat, M.D., Representative

Report of the Delegate to the American
Medical Association

Your delegate attended all meetings of the House of
Delegates during 1957. In addition, he continues to
serve the association in a number of other capacities.

A complete report of the transactions of the House of
Delegates appears in the J.A.M.A., covering both the
annual session in New York and the clinical session in
Philadelphia. Some of the more important actions taken
by the House are as follows:

Dr. Gunnar Gundersen, of LaCrosse, Wisconsin, a
long-time member of the Board of Trustees and well
known to physicians in this area was unanimously elect-
ed president-elect for 1958 and will assume office as
president in June 1958. Dr. David Allman of Atlantic
City is currently serving as president.

Every year the House of Delegates votes a distin-
guished service award to an outstanding American phy-
sician. This year it was given to Dr. Tom Douglas Spies,
head of the Department of Nutrition and Metabolism at
Northwestern University School of Medicine in Chicago,
widely known for his outstanding contribution to the
science of human nutrition. The House also voted a spe-
cial citation to a nonmedical man for outstanding service
in advancing the ideals of medicine. The recipient of this
award was Henry Viscardi, Jr., founder and president
of Abilities, Inc., which employs only severely disabled
persons.

The House adopted the long discussed revision of the
principles of medical ethics. The new principles of med-
ical ethics read as follows:

“These principles are intended to aid physicians indi-
vidually and collectively in maintaining a high level of
ethical conduct. They are not laws but standards by
which a physician may determine the propriety of his
conduct in his relationship with patients, colleagues,
members of allied professions, and the public.

“Section 1. The principal objective of the medical
profession is to render service to humanity with full re-
spect for the dignity of man. Physicians should merit the
confidence of patients entrusted to their care, rendering
to each a full measure of service and devotion.

“Section 2. Physicians should strive continually to im-
prove medical knowledge and skill and should make
available to their patients and colleagues the benefits of
their professional attainments.

“Section 3. A physician should practice a method of
healing founded on a scientific basis; and he should not
voluntarily associate professionally with anyone who
violates this principle.

“Section 4. The medical profession should safeguard
the public and itself against physicians deficient in moral
character or professional competence. Physicians should
observe all laws, uphold the dignity and honor of the
profession, and accept its self-imposed disciplines. They
should expose, without hesitation, illegal or unethical
conduct of fellow members of the profession.

“Section 5. A physician may choose whom he will
serve. In an emergency, however, he should render serv-
ice to the best of his ability. Having undertaken the
care of a patient, he may not neglect him; and, unless
he has been discharged, he may discontinue his services

SEPTEMBER 1958

403

only after giving adequate notice. He should not solicit
patients.

“Section 6. A physician should not dispose of his serv-
ices under terms or conditions which tend to interfere
with or impair the free and complete exercise of his
medical judgment and skill or tend to cause a deteriora-
tion of the quality of medical care.

“Section 7. In the practice of medicine, a physician
should limit the source of his professional income to
medical services actually rendered by him, or under his
supervision, to his patients. His fee should he commen-
surate with the services rendered and the patient’s abil-
ity to pay. He should neither pay nor receive a commis-
sion for referral of patients. Drugs, remedies, or appli-
ances may be dispensed or supplied by the physician
provided it is in the best interests of the patient.

“Section 8. A physician should seek consultation upon
request, in doubtful or difficult cases, or whenever it
appears that the quality of medical service may be en-
hanced thereby.

“Section 9. A physician may not reveal the confidences
entrusted to him in the course of medical attendance, or
the deficiencies he may observe in the character of pa-
tients, unless he is required to do so by law or unless
it becomes necessary in order to protect the welfare of
the individual or of the community.

“Section 10. The honored ideals of the medical pro-
fession imply that the responsibilities of the physician
extend not only to the individual but also to society
where these responsibilities deserve his interest and par-
ticipation in activities which have the purpose of improv-
ing both the health and the well-being of the individual
and the community.”

For many years, as has been frequently pointed out
in these annual reports, the basic problem affecting the
practice of medicine today is that of third-party inter-
vention and control of medical practice. Despite vigor-
ous efforts on the part of the profession, there has been
a gradual encroachment on the field of professional con-
trol of medical practice. During the past number of
years, various local medical societies have been experi-
encing difficulties with the operations of the United Mine
Workers of America Welfare and Retirement Fund. This
fund was set up to provide medical and other welfare
services to members of the United Mine Workers Union,
and, in the beginning, medical care was paid for on a
"fee for service with free choice of physician basis.”
Over a period of years, this concept has been abandoned
by the directors of the fund, and they have in recent
years dictated who may or may not treat a recipient of
aid from the hospitals providing care to mine workers.
This, of course, has resulted in a disruption of the pa-
tient-physician relationship. At the New York meeting,
there was an intense, bitter discussion of this problem,
which resulted in the acceptance by the A.M.A. but not
by the UMW of a set of guides outlining both medical
society and UMWA responsibilities. These guides may be
summarized as follows:

1. All persons, including the beneficiaries of a third-
party medical program such as the UMWA Fund, should
have available good medical care and should be free to
select their own physicians from among those willing
and able to render such service.

2. Free choice of physician and hospital by the patient
should be preserved:

a. Every physician duly licensed by the state to prac-
tice medicine and surgery should be assumed at the
outset to be competent in the field in which he
claims to be, unless considered otherwise by his
peers.

b. A physician should accept only such terms or con-
ditions for dispensing his services as will insure his
free and complete exercise of independent medical
judgment and skill, insure the quality of medical
care, and avoid the exploitation of his services for
financial profit.

c. The medical profession does not concede to a third
party, such as the UMWA Welfare and Retirement
Fund, in a medical care program the prerogative of
passing judgment on the treatment rendered by
physicians, including the necessity of hospitaliza-
tion, length of stay, and the like.

3. A fee-for-service method of payment for physicians
should be maintained except under unusual circum-
stances. These unusual circumstances shall be determined
to exist only after a conference of the liaison committee
and representatives of the fund.

4. The qualifications of physicians to be on the hos-
pital staff and membership on the hospitals staffs are to
be determined solely by local hospital staffs and by local
governing boards of hospitals.

The House of Delegates reiterated their opposition to
compulsory inclusion of physicians in the federal social
security system. They continued their support of legis-
lation of the Jenkins-Keogh type.

At the December session in Philadelphia, the delegates
gave unqualified endorsement to fluoridation of water
as an aid to the prevention of dental caries.

The delegates continued to support the issue of free
choice of physician and opposition to third-party inter-
vention and control. The following resolution introduced
by the delegate from South Dakota was adopted, “Re-
solved that the House of Delegates affirm that it is
within the limits of ethical propriety for physicians to
join together as partnerships, associations, or other law-
ful groups, provided that the ownership and manage-
ment of the affairs thereof remains in the hands of li-
censed physicians.

The most important matter considered this year had to
do with the entire reorganization of the A.M.A. struc-
ture. As has been previously reported, the A.M.A. em-
ployed a firm of management consultants, Robert Heller
and Associates, to advise on improvement of the business
methods of the association. This report was received and,
in the main, adopted, resulting in a reorganization of
the offices of the association somewhat along the follow-
ing lines. The office of secretary and treasurer will be
combined and will be selected from one of the Board of
Trustees. The office of general manager will be discon-
tinued and a new office of executive vice-president estab-
lished. This has all been done and former general man-
ager, Dr. George Lull, who is known and revered by all
physicians in America, will remain as a consultant and
the position of executive vice president will be filled by
Dr. F. J. L. Blasingame. Various other changes in the
organizational structure were effected, perhaps the most
important of which was the appointment of a new busi-
ness manager who will reorganize the business structure
of the organization. In addition, the Board of Trustees
intends to spend a considerable sum of money renovating
the headquarters at 535 North Dearborn. It intends to
put in air conditioning and other improvements so that
the building will be more modern and more functional.

Probably one of the most serious threats to American
medicine today consists of the proposals embodied in the
Forand bill and other related changes which would ex-
tend medical benefits to certain social securitv recipients.
The A.M.A. has organized a strong group which will not
only vigorously oppose such ill conceived suggestions as
those embodied in the Forand bill but will vigorously

404

THE JOURNAL-LANCET

propose constructive alternatives. As everyone in our
association knows, one of the pressing problems affecting
medical practice today is the proper care of the aging
population. Doctors individually and the A.M.A. have
been vigorously investigating the problems involved in
care of the aged. In this they have not only been con-
cerned with the medical problems but have also consid-
ered the various social and economic factors involved.
The A.M.A. Committee on Aging and other portions of
the organization have cooperated with other groups in-
terested in this particular field. The type of constructive
approach, which will undoubtedly be favored by our
association, will be along the line of an attempt to ex-
tend insurance benefits to the aging, a program of pro-
viding proper facilities for the care of the aging who do
not need general hospital care, a program for the provi-
sion of assistance and some type of care in the home
where that is possible. Other programs are under con-
sideration, and it seems likely that improvement in the
over-all care of the aging will result from these efforts.

In the legislative field, it is humiliating to note that
a representative from North Dakota has introduced an
anti-vivisection bill in the Congress.

It is the feeling of many of us who have been actively
engaged in the work of the A.M.A. for a number of years
that, during the past, there has been a revitalization of
its efforts. We believe that the association is going for-
ward more actively than ever to work for those things
which are in the best interest of the medical profession
and the people of our country. Certainly it can be said
that the A.M.A. deserves the strong support of every
doctor.

W. A. Wright, M.D., Delegate

Committee on Necrology and Medical History

Alas for him who never sees

The stars shine through the cypress-trees!

Who, hopeless, lays his dead away.

Nor looks to see the breaking day
Across the mournful marbles play!

Who hath not learned, in hours of faith,

The truth to flesh and sense unknown,

That Life is ever Lord of Death
And Love can never lose its own!

John Greenleaf Whittier

WILLIAM W. WOOD, M.D.

Dr. William W. Wood, 77, for many years a physi-
cian in Jamestown and one of the founders of the James-
town Clinic, died May 1, 1957, in Fort Worth, Texas.

Dr. Wood went to Jamestown June 1, 1909, from
Jasper, Minnesota, where he had practiced briefly after
graduating from the University of Illinois Medical Col-
lege and serving as intern in 2 hospitals.

For twenty-five years, Dr. Wood was treasurer of the
North Dakota State Medical Association and was a Fel-
low of the American College of Surgeons. He was a
member of a number of medical societies.

Failing health led Dr. Wood to retire several years ago,
and he usually spent the winters in San Antonio and
Fort Worth and the summer months at Jamestown and
on Detroit Lake.

He was a member of the Elks, the Masons, and the
Shrine.

He was the son of Mr. and Mrs. James M. Wood,
natives of Scotland. He married Miss Mollie Hansen,
a native of Denmark, and they became parents of 2 sons
who became physicians. They are Dr. William W. Wood,
Jr., Fort Worth, and Dr. Robert A. Wood, Shebovgan,
Wisconsin. Mrs. Wood and the sons survive.

HENRY M. WALDREN, JR., M.D.

Dr. Henry M. Waldren, Jr., 55, of Drayton, died sud-
denly in his home July 2, 1957.

Dr. Waldren was born in Drayton, the son of Dr. and
Mrs. H. M. Waldren, Sr. After completing his public
school education at Drayton, he attended the University
of North Dakota. He graduated from Northwestern Uni-
versity in 1925 with a doctor of medicine degree and
interned the next two years at Charity Hospital, New
Orleans. He then returned to Drayton and began the
practice of medicine with his father.

Since the death of his father several years ago, he had
been chief physician and surgeon at the Drayton Hos-
pital, which his father operated for many years.

Dr. Waldren was prominent in civic activities. He
served several years as Pembina county health officer
and was a member of various Masonic organizations,
having served as North Dakota Masonic district deputy
for four years. He was city health officer at Drayton at
the time of his death. He was a member of Sigma Nu
social fraternity. Phi Beta Pi medical fraternity, and was
a charter member of the American Academy of General
Practitioners of North Dakota at the time of his death.

He is survived by his wife, a daughter, and a son.
Dr. II. M. Waldren, Jr., of Mlwaukee.

ADRIAN E. DONKER, M.D.

Dr. A. E. Donker, 75, retired physician and surgeon
of Carrington, died July 29, 1957. He had been in fail-
ing health for five years.

A graduate of the University of Michigan, Dr. Donker
came to North Dakota in 1913, practicing at Sykeston
until 1923 when he went to Carrington.

He was a former member of the Tri-County District
Medical Society and retired from active practice in 1947.

He is survived by his second wife and 2 daughters.

WALTER H. GILSDORF, M.D.

Dr. Walter H. Gilsdorf, 56, of Valley City, died on
September 20, 1957, in a local hospital after suffering
a heart attack earlier in the day.

Dr. Gilsdorf was born June 26, 1901, in Wabasha,
Minnesota, and was graduated from high school there.
He graduated from the University of Minnesota School
of Medicine in 1931 and practiced two years in Dickin-
son, North Dakota, and twelve years at New England,
North Dakota, before coming to Valley City in 1945.

Dr. Gilsdorf was a member of the Valley City school
board and the Community Chest board and was a di-
rector of the Fidelity Savings and Loan Association. He
was chairman of the health and safety program of the
Red River Valley Council of Boy Scouts and past chair-
man of the Barnes district. He was a trustee of Our
Saviour Lutheran Church in Valley City.

He was a member of state and national medical groups,
the Elks lodge, and Knights of Pythias. For several
years, Dr. Gilsdorf was active in the affairs of the North
Dakota State Medical Association. He was a member
of the House of Delegates for several years and, at the
time of his death, was the councillor for the Sheyenne
Valley District Medical Society.

Surviving are Mrs. Gilsdorf and 4 sons, Walter, a stu-
dent at Harvard University; Robert and John, students
at the University of North Dakota; and James, who is
at home.

KENNETH M. MURRAY, M.D.

Dr. K. M. Murray, of Scranton, died at his home
December 21, 1957. He was 77 years old. He was born
December 21, 1880, in Woodstock, Ontario, where he

SEPTEMBER 1958

405

received his education. Upon completing his course of
instruction required to receive a teacher’s certificate, he
taught school for several years. The desire to study medi-
cine had been strong in him since he was a hoy, and,
thus, he found himself entering the University of Toron-
to and graduating with the class of 1909.

In 1910, he came to Scranton and had been the family
doctor for hundreds of families there ever since. He had
been a member of the Southwestern District Medical
Society and the North Dakota State Medical Association
since 1924. In 1955, when Dr. Murray had practiced in
Scranton for forty-five years, the community put on a
celebration and named the park “Murray Park.”

He is survived by his wife and an adopted son.

JOHN G. LAMONT, M.D.

Dr. John G. Lamont, former superintendent of the
Grafton State School and before that of San Haven Sana-
torium at Dunseith, died January 7, 1958, in Oklahoma
City, where he had lived since his retirement in 1953.
He was 87 years old at the time of his death.

Dr. Lamont, a native of Ontario, received his medical
degree in Trinity University Medical College in Toronto
and served as house surgeon in Toronto General Hospital
before coming to Cando, North Dakota, in 1901. He
practiced at Cando eleven years before his appointment
as superintendent and medical director at San Haven,
where he served sixteen years. He became superintend-
ent of the Grafton State School in 1939.

Throughout his adult life, he was active in profes-
sional and fraternal organizations. He was a “50-Year
Club” member and an honorary member of the North
Dakota State Medical Association.

He is survived by his wife and 3 daughters, Mrs.
Chilton Powell, wife of the Episcopal bishop of Okla-
homa; Joyce, of Minneapolis; and Alwvn, of Detroit.

EDWARD S. O’HARE, M.D.

Dr. Edward S. O’Hare, 71, Esmond physician for many
years, died February 7, 1958, in Tacoma, Washington.
Dr. O’Hare was stricken by a heart ailment while vis-
iting a daughter.

Born in Minneapolis, Dr. O’Hare graduated from the
University of Minnesota School of Medicine in 1914.

He had been a general practitioner and a branch-line
surgeon for the Northern Pacific Railway at Esmond for
thirty-three years. He was a former member of the
Devils Lake District Society.

Dr. O Hare’s wife preceded him in death. He leaves
2 sons and 4 daughters.

E. H. Boerth, M.D., Chairman

Committee on Public Health

A joint meeting of the Public Health Committee and
the North Dakota State Health Council was held at the
Capitol Building, Bismarck, September 22, 1957.

The purpose of this meeting was to make recommen-
dations necessary to cope with Asian influenza should it
develop in epidemic form in Nortli Dakota.

The use of influenza vaccine in maximum amounts was
advised as it is the only known preventive. Emphasis
was placed on the fact that the vaccine was distributed
through regular pharmaceutical channels and that the
North Dakota State Department of Health has no funds
for purchase or distribution of the vaccine.

The 6 manufacturers of Asian influenza vaccine were
allocating the vaccine to the states on the basis of popu-
lation. Nortli Dakota received .4 of 1 per cent of the
total available commercial supply.

The recommendations of the A.M.A. and the State and
Territorial Health Officers Associations were to be effec-
tive during the short supply. These were as follows —
priorities being given to: (1) individuals whose services
are necessary to maintain the health of the community,
( 2 ) individuals who are needed to maintain other basic
community services, and ( 3 ) persons with tuberculosis
and others who, in the opinion of the physician, consti-
tute a special medical risk.

It was pointed out that studies in military services
revealed that the present vaccine with 1 injection per
individual is about 70 per cent effective.

Contraindications to the use of the vaccine were noted,
such as sensitivity to eggs, chickens, or chicken feathers.

Hospital beds were to be reserved for those with com-
plications.

The North Dakota State Health Department was en-
couraged to prepare and distribute educational material
on home care of influenza cases.

District medical associations, local communities, and
local health organizations were advised to make any
preparation necessary in case influenza should strike a
community.

No recommendations were made concerning dosage
and method of administration of the vaccine.

The group appointed the following as a state advisory
committee on influenza to function through the North
Dakota State Health Department and the North Dakota
State Medical Association in case of an epidemic in
North Dakota: Dr. Percy L. Owens, chairman, Bismarck;
Dr. G. R. Richardson, Minot; Dr. M. S. Jacobson,
Elgin; Joe Halbeisen, druggist, Fargo; Sister M. Angele,
Garrison Community Hospital; and VV. Van Heuvelen,
executive officer, State Health Department, Bismarck.

Your chairman has continued to function on the polio-
myelitis vaccine advisory committee, receiving stated
reports from the Preventable Disease Division of the
State Health Department. Whereas, heretofore the prob-
lem was that of insufficient vaccine, we have now a suf-
ficient amount but an apathy on the part of the public
to take advantage of it.

Latest statistics as of February 28, 1958, show the total
eligible population to be 413,085, and only 222,229, or
55.4 per cent, have received the first dose; 201,632, or
48.8 per cent, have received the second dose; and
135,027, or 32.6 per cent, the third dose.

It is hoped the publicity on a national, state, and
local level will increase the number of persons receiving
the vaccine before the polio season rolls around.

As there is no venereal disease committee, the State
Health Department has asked me to report that 24 cases
of syphilis and 176 cases of gonorrhea were reported
in 1957. The cases of syphilis are tabulated as follows:
primary and secondary — 0, late latent — 9, neurosyphilis —
1, congenital — 1, earlv latent — 2, late tertiary — 8, cardio-
vascular— 1, and not given — 2.

Your chairman does not attempt to draw any conclu-
sions from these figures except to note that gonorrhea
and syphilis are still with us but in tremendously re-
duced numbers.

Percy L. Owens, M.D., Chairman

Committee on Official Publication

The Committee on Official Publication held no meet-
ings during 1957.

At the annual meeting of the North Dakota State
Medical Association, held in Fargo in May, 1957, the
House of Delegates voted for a three-year contract with
The Journal-Lancet. The contract still has two years
to run.

406

THE JOURNAL-LANCET

The committee will welcome any suggestions if any
member of the association desires any change in The
|ournal-Lancet regarding publication, number of re-
prints of articles, and so forth.

E. II. Boerth, M.D., Chairman

Committee on Legislation

This year the Legislative Committee has held no spe-
cific meeting as of March 18, 1958. There has been no
specific need for a comprehensive legislative meeting of
the committee, since there is no legislative session in
North Dakota this year. Next year we are faced with
another session and with the possibility of many legis-
lative actions by the legislature. A meeting of this com-
mittee is slated for March 30 for the purpose of discuss-
ing the Forand bill with an A.M.A. representative. Pri-
marily, the legislative activity of your chairman has been
to watch over what national legislation may be in the
hopper in Washington and to contact the North Dakota
delegation of representatives and senators from this state
in Washington relative to the specific national legislative
bills.

One of the bills at the present time that will be before
the House very shortly is the Forand bill which might
affect the practice of medicine considerably. If this bill
is passed, it would in all eventualities grant full medical
and hospitalization care for any individual who is receiv-
ing social security and, hence, would be a rather rapid
step toward full socialization. In the bill, one specific
clause has been set up for the specific purpose of set-
ting physicians against each other by allocating certain
privileges to specific classes of physicians and not the
same privileges to another group. This, of course, is dis-
crimination, which we can expect with any socialized
legislation. It is simply an indication of what full so-
cialization may, and would do, to the average physician.
Those who are good politicians would definitely have the
advantage over those whose public relations might not
be quite as finely polished. Likewise, there is little ques-
tion about the fact that specialists would be granted cer-
tain privileges which general practitioners would not re-
ceive. Whether this is good or bad is not for me to report
in this report. You may draw your own conclusions.

Another bill which is to again be considered within
this next Congress is the Jenkins-Keogh bill, granting the
physician the privilege of setting aside a certain per-
centage of his earnings for retirement. This is done in
view of the fact that the physician is not included in
social security. He has not been included because of his
desire to be left on the outside, and I am in accord with
such a decision. It is the impression and opinion of
your chairman that, should we accept any privileges in-
cluding social security, we would simply be advancing
one step closer to and condoning socialized medicine.

O. W. Johnson, M.D., Chairman

Committee on Public Relations

The chairman of the Committee on Public Relations;
Dr. Rodgers, the state president; and Mr. Lyle Limond,
the executive secretary, attended the Public Relations
Conferences at the Drake Hotel in Chicago, which were
again sponsored by the A.M.A.

We received valuable help and aid in promoting a
sound basis of public relations both on the state society
level as well as on the local level. With this as a base,
Mr. Limond has given several talks on the matter of
public relations, especially with the view to the physi-
cians’ office personnel. Fortunately, the majority of the
other states have far different problems than we find
here in North Dakota, and our activity has been mostly

confined to the national political scene in cooperating
with the public relations department in the A.M.A. head-
quarters.

Mr. Limond has been to several meetings, including
the press and legal conferences, and has submitted our
relationships very effectively. On the local level, we
have carried out career night plans for youngsters with
several physicians participating, and several talks have
been given at local P.T.A.’s and clubs.

We have also in the past month been responsible for
disseminating literature to various television newscasts
throughout the state and bringing to the attention of the
public the recent National Health Week.

I believe this committee has been very effective in
promoting a joint understanding between several profes-
sional groups throughout the state and has succeeded in
acquiring favorable publicity from local television and
radio networks.

John T. Cartwright, M.D., Chairman

Committee on Medical Economics

Most of the accomplishments of this committee took
place at our fall meeting on October 19, 1957, in Bis-
marck.

Union Life Insurance Company representatives pre-
sented to this committee a group plan for life insurance
for the doctors of the North Dakota medical society.
This plan presents a good deal of saving on life insur-
ance, and it was adopted by the committee and later by
the council of our state society. It requires no evidence
of insurability, and its premium rates on the group basis
are much cheaper than a comparable nongroup policy.
Dividends will be payable to the North Dakota State
Medical Association and their ultimate disposition is at
the discretion of the association.

Mr. Ralph Atkins explained the change in vendor pay-
ment procedures in public assistance cases. The doctor
of medicine no longer receives vendor payments. The
payments for medical care ( physician services ) go di-
rectly to the recipient, and the recipient is to pay the
doctor. Matching money would be lost if the doctor was
on the vendor payment, according to the recent change
in the Social Security Law. All doctors in the state have
received a letter to this effect.

Dr. Foster moved that the House of Delegates of the
North Dakota State Medical Association seriously con-
sider passing a resolution urging the A.M.A. to make
efforts to have an amendment to the Social Security Act
passed in Congress, which would return to the program
of complete vendor payments. Motion was seconded by
Dr. Mahoney and carried.

Discussion turned next to the proposal of drawing up
a relative value schedule in North Dakota for the classifi-
cations of (a) medical services, (b) surgery, (c) radi-
ology, and ( d ) pathology. Dr. Peters moved that the
North Dakota State Medical Association adopt a relative
value schedule based, in principle, upon the California
Medical Association’s relative value schedule and that the
schedule be subject to revision in the future as felt neces-
sary in the light of experience by the Committee on
Medical Economics. This proposal was seconded by Dr.
Borland and carried.

This relative value fee schedule in no way sets any-
one’s fees or anyone’s schedule of fees. What it does do
is create a list of relative values which are not expressed
in dollars but are expressed in units. These units in each
procedure can be converted into dollars by the use of
a conversion factor. The conversion factor for private
fees can be determined by the physician to meet that
which he wishes to charge patients in the territory in

SEPTEMBER 1958

407

which he practices and may be changed at any time to
compare with the economic situation of the time. The
advantages of this system are many. Expressed in units,
it may be used as a guide in setting up governmental
schedules and private fee schedules by using a conversion
factor to meet the schedule desired. An entire govern-
mental or private schedule may be changed to meet the
conditions of the time by changing only the conversion
factor. It does not require a complete revision of the
entire schedule. It gives a true relationship or relative
value that one procedure bears to another and in no way
dictates the private fees to be charged. These are deter-
mined by the physician himself in the conversion factor
he chooses to use.

This committee hopes that the relative value schedule
will be adopted bv the House of Delegates at their 1958
meeting. If adopted, the schedule will be submitted to
the various specialty groups for changes they wish to
make to meet the conditions in this state. After this has
been accompilshed, the Medical Economics Committee
will again meet to determine nonspecialty procedures
and to adopt the entire schedule as revised to meet this
state’s requirements. A relative value fee schedule then
will be sent to each doctor in the state. I request that
a budget for the printing and mailing of these schedules
be considered.

Conversion factors for governmental schedules were
discussed by your committee and follow:

Indian Bureau fee schedule and Welfare schedule.
These schedules were discussed together, since the com-
mittee thought that the 2 fee schedules were quite com-
parable. The conversion factors decided upon were as
follows: surgery — 2.85, medical services — 2.67, pathol-
ogy— 2.25, and radiology — 3.75.

Dr. Foster moved that the North Dakota State Medical
Association negotiate in the future with the State Wel-
fare Board and the Indian Bureau, using the above listed
conversion factors and not lowering these factors. Motion
was seconded by Dr. Richardson and carried.

Workmen’s Compensation fee schedule. Dr. Mahoney
moved that the North Dakota State Medical Association
negotiate with the Workmen’s Compensation Bureau and
not go below the average fee schedule conversion factors.
The conversion factors are to be as follows: surgery —
4.28, medical services — 4.00, pathology — 3.00, and radi-
ology— 5.00. Motion was seconded by Dr. Borland and
carried.

Vocational Rehabilitation fee schedule. Dr. Foster
moved that the North Dakota State Medical Association
negotiate in this area using the average fee schedule
conversion factors ( same as Workmen’s Compensation
schedule) as a basis. Motion was seconded by Dr. Ma-
honey and carried.

Crippled Children Services fee schedule. Dr. Peters
moved that the House of Delegates go on record stating
that all fee schedules involving members of the North
Dakota State Medical Association be approved by the
association and that no changes be made in these sched-
ules without mutual consent of the parties involved.
Motion was seconded by Dr. Borland and carried.

Dr. E. T. Keller was asked to comment on the un-
approved portions of the C.C.S. schedule at the next
meeting of the Special Advisory Committee to Crippled
Children Services.

Medicare. Dr. Peters stated that representatives of the
North Dakota State Medical Association were to be
called in to Washington, D.C., in January 1958 for the
purpose of renegotiating our Medicare contract with the
Department of the Army. Dr. Peters also mentioned

that there were a few changes to be asked for in the
fee schedule.

Dr. Keith Foster moved that the Medical Economics
Committee commend the negotiating team, Dr. Peters
and Mr. Limond, of 1956 for its efforts in securing a
fair and reasonable contract and that the same basis of
negotiation be used in 1958 as was used in 1956. Motion
was seconded by Dr. Borland and carried.

North Dakota High School League fee schedule. The
Medical Economics Committee recommend that efforts
be made to inform the North Dakota High School Ac-
tivities Association that each superintendent of schools
should stress the true aspects of this plan and also state
that the group accident benefit fund is not one of full
coverage.

This chairman feels that this committee has initiated
an important and necessary advance by establishing a
relative value fee schedule, but much more work needs
to be transacted by the committee to complete the sched-
ule as dictated by this state’s needs. This shall be done
after adoption by the House of Delegates.

E. T. Keller, M.D., Chairman

Committee on Prepayment Medical Care

This committee did not hold a meeting this past year.
Many of its members have also been members of the
Medical Economics Committee, which has been quite
active during the past years. A survey by mail was made
of the members of this committee of all topics it was felt
well to discuss, and we found that in most instances
these subjects had already been covered by the Medical
Economics Committee. This duplication of effort by the
Medical Economics Committee and the Prepaid Medical
Committee does not seem justified in view of the fact
that most of the work eventually has to be reviewed
and passed upon by the Medical Economics Committee.
Our present prepaid medical plans in North Dakota, such
as Blue Shield and Blue Cross, are functioning well with
very close liaison with the state medical association. The
original purpose of the Prepaid Medical Committee was
to work with and help develop Blue Shield and Blue
Cross in this state. This having been accomplished, it
is now felt that there is too much overlapping of the
functions of the Medical Economics and Prepaid Med-
ical Plan Committees.

Therefore, it was recommended to the council at their
meeting in Fargo on December 14, 1957, that the Pre-
paid Medical Committee be abolished and that such
work as might fall to this committee be handled by the
Medical Economics group. I believe the new Constitu-
tion and Bylaws will also indicate that this committee
has been abolished and made a part of the Medical Eco-
nomics Committee.

In January, 1958, Dr. R. W. Rodgers, president of the
North Dakota State Medical Association; Mr. Lyle Li-
mond, executive secretary; and I comprised a committee
that met with the Department of the Armv in Washing-
ton, D.C., to renegotiate the Medicare contracts. Once
again, we have obtained a maximum fee schedule which,
I believe, will be fair to our entire membership and
which should function well under the plan that has been
in effect for the past several months. As you may recall,
at the time this contract was first put into effect in De-
cember 1956, it was voted by the council not to publish
this fee schedule. At the House of Delegates meeting in
May 1957, the philosophy of this program was discussed
and the action of the council in determining that this
fee schedule should not be published was agreed upon
and endorsed by the House of Delegates without a dis-

408

THE JOURNAL-LANCET

senting vote. During the intervening months, claims
have been processed through the executive secretary’s
office and forwarded to the fiscal agent, the Wisconsin
State Medical Society. This program lias run smoothly
with a minimum amount of discontent. Each physician
has submitted his usual, customary, reasonable fee for
his services, which, in effect, is the fee schedule as far
as he is concerned. The Washington office of Medicare
has been very happy with the way the program has been
developed and run in North Dakota. Its experience with
our maximum schedule, without our fee schedule being
published, has been much more successful than in those
40-odd states and territories in which a schedule has
been published. The Arbitration Committee, appointed
by the state president of the association to go over any
difficulties arising from this plan, met once in Bismarck
during 1957. This is an indication, I believe, of the
minimum amount of difficulty that we have encountered.
In many states, such committees have been meeting
monthly and, occasionally, even on a semimonthly basis.

During 1958 we anticipate that this program will be-
come enlarged due to increased military personnel in the
cities of Minot and Grand Forks. We also have reason
to believe that these programs are being carefully scru-
tinized and watched by various agencies in govern-
mental circles in Washington. We continue to feel that
if the philosophy of our present program can be con-
tinued and reasonably and fairly developed as it has in
the past year and a half, that other programs in the
future may preserve the practice of medicine in this
state along the lines that we have enjoyed in the past.

C. H. Peters, M.D., Chairman

Committee on Veterans Medical Service

There has been no meeting of the Veterans Medical
Service Committee during the past fiscal year. No mat-
ters have been reported to this committee for their con-
sideration.

A. C. Fortney, M.D., Chairman

Committee on Rural Health

Our Committee held no formal meeting this past year.
It is hoped that plans in the mind of the present chair-
man will jell so that this committee will become active
in projects again.

M. S. [acobson, M.D., Chairman

NEW BUSINESS

Secretary Boerth read a letter addressed to Dr. Dodds
from Dr. W. A. Wright, delegate to the A.M.A., which
stated that he would be unable to attend the House of
Delegates session as he was called to a meeting of a
committee of the A.M.A. of which he is a member.
Speaker Dodds acknowledged the letter with a comment
of regret.

Speaker Dodds next introduced Mr. Hohlmeyer of the
Union Central Life Insurance Company, who spoke as
follows :

“Briefly, the type of coverage placed in force in your
association is group term insurance. The amount of cov-
erage is $20,000 for those under age 50; $15,000 for
those of ages 50 to 59 inclusive; $10,000 for those of
ages 60 to 64; and $6,500 for ages beyond 64. It is
available without any evidence of insurability; the cost
is roughly $.50 on the dollar as it gives you the oppor-
tunity through mass buying to secure coverage at a
cheaper rate. It has no cash value. Premiums are on a
semiannual basis.

“This is a participating policy. Like all group insur-
ance, what you buy is on a cost plus basis. The majority
of the members of this group policy in the state have
used their dividends to reduce premiums.”

Dr. Nugent asked Mr. Hohlmeyer if there was any
provision whereby the individual member will be guar-
anteed renewal. Mr. Hohlmeyer replied as follows:

“On the question of renewal, the master policy con-
tains a provision that it can be canceled at the option
of the company or the policyholder. The only reason a
group policy of this type would be canceled would be
because the number of participants were lowered; for
instance, if there were only 75 to 80 lives insured, we
would wonder about continuing this policy. The indi-
vidual participant has a right to convert to permanent
insurance while the policy is in force. We will continue
this coverage without any question with 150 lives in-
sured at the end of the year. That is our minimum
objective.

“We would rather have you people follow the rules
regarding the semiannual premium. You do have thirty
days grace on this payment. If you pay an annual pre-
mium, it involves a great deal more bookkeeping for
our office.

“I do not have the exact figures regarding the average
group of the participating physicians so far but believe
that in your group, approximately two-thirds to three-
fourths are for $20,000. One thing I could add is that
this insurance is one piece of property you own which
can bypass the estate tax. This policy can be so assigned
to either your wife or children that it will not be a part
of your estate, regardless of the fact that you are paying
the premiums. In an ordinary life policy, you have cash
values and you are, therefore, making a gift of that
policy which will be subject to a gift tax. However, in
this policy, there is no cash value and that is why the
estate tax can be avoided.

“The enrollment on this policy will be open for the
balance of the first contract year, that is until February
1959. New members of your association can come in
at any time within the first six months of their member-
ship in this association. After that, they can come in
but must furnish evidence of insurability.”

Speaker Dodds thanked Mr. Hohlmeyer. He then com-
mented that the House was honored by the presence of
the president, Dr. Rodgers, and welcomed him, asking
if he cared to make any statement to the delegates at this
time. Dr. Rodgers declined, saying only that he was
happy to be present.

Speaker Dodds was asked to advise the delegates re-
garding the interim session of the A.M.A. in Minneapolis
on December 2 to 5 of this year. As far as the meeting
in Minneapolis is concerned, all of the members of the
House should try to make an effort to be there. No doubt
some of the members will be called upon to help out in
the promotion of our cause.

Dr. V. G. Borland, councillor of the First District,
was next called upon to give a brief explanation of a
matter which had come before the council. He spoke
as follows:

“This is in reference to the proposed group insurance
for a malpractice plan that the council has considered.
The proposal was placed in such a way that money could
be saved on premiums. At this time, a survey will be
conducted to see whether you want to consider this plan.
If you are interested, the survey will be just a matter
of answering a few questions to acquire some informa-
tion. No further action will be taken until the council
meets on this again after this survey.”

The next order of business was the announcement of

SEPTEMBER 1958 409

the Nominating Committee. Dr. Boertli, secretary, an-
nounced that Dr. Rodgers, our president, had appointed
Drs. Ted Keller, chairman, and A. K. Johnson and F. A.
DeCesare to the Nominating Committee.

Dr. Gillam next presented the following resolution to
the Committee on Resolutions for their consideration:

RESOLUTION

Whereas, a large number of physicians in North Dakota are
represented much of the time in their public relations by lay per-
sons acting as business managers, and

Whereas, these business managers have the best interest of
their physician associates in mind, and

Whereas, these business managers might better be indoctrinated
in and informed of the principles and procedures of medical legis-
lation,

Be it resolved that any physician or group of physicians may
recommend through its district medical society that such lay busi-
ness managers are responsible and should have the opportunity to
be considered “observers” at state medical association delibera-
tions, and

Be it further resolved that if district approval is accomplished,
the credentials committee shall be authorized to accept these indi-
viduals as “observers.” An “observer” shall be a lay person so
recommended who shall be seated in an area designated for “ob-
servers” and who cannot receive chair recognition or voting privi-
leges. Accredited “observers” should be listed in the Handbook
and receive copies prior to the meeting.

This resolution was referred to Dr. Pederson’s Com-
mittee on Resolutions.

Dr. Nugent next presented a resolution as follows:

RESOLUTION

Whereas, the Committee on Medical Economics has adopted a
relative value schedule based upon the California Medical Asso-
ciation’s relative value schedule, and

Whereas , the Committee on Medical Economics has submitted
the schedule to the various specialty groups for changes they wish
to make to meet the conditions in this state, and

Whereas, the Committee on Medical Economics is asking that
the relative value schedule be adopted by the House of Delegates
at their 1958 meeting.

Therefore , be it resolved that the council of the North Dakota
Academy of Ophthalmology and Otolaryngology recommend to the
Committee on Medical Economics and to the House of Delegates
of the North Dakota Medical Association that the California Med-
ical Association Relative Value Schedule as it pertains to the
specialties of ophthalmology and otolaryngology be adopted with
the following changes:

Item Present Suggested

No. Procedure value change

5435 R refraction without cycloplegia 2.5 3.0

5436 Refraction with cycloplegia 3.5 3.0

5501 Sclerectomy for glaucoma with scissors,

punch, or trephine 80.0 50.0

5616 Removal of dislocated lens 100.0 75.0

5641 Myotomy, tenotomy, recession, resection,
advancement of, shortening of ocular
muscles for strabismus — one or more

stages, unilateral 50.0 50.0

5642 Bilateral 60.0 60.0

( It is noted that there is no change in the above items, but
that they are to be interpreted as applying to any initial
procedure, whether planned for one stage or multiple stages.)

5643 One muscle, initial 30.0 Delete the

item entirely

5646 Subsequent muscles 20.0 30.0

Dr. Dodds, speaker, commented that the chair would

divert from the usual practice and that he would refer
this resolution to Dr. Baumgartner’s committee to con-
sider the report of the Committee on Medical Economics.

Dr. E. G. Vinje next presented a resolution, stating
that although he was a delegate from the Sixth District
Medical Society, he assumed sole responsibility for pre-
senting the resolution.

RESOLUTION

Whereas, North Dakota is the only state in the United States
which does not have a doctor of medicine as state health officer,
and

Whereas, the salaries of state health officers in these 48 states
averages $12,500 per year.

Therefore, be it resolved that the North Dakota State Medical
Society recommend to the legislative research committee that they
introduce a bill at the 1959 legislative session appropriating an
amount of $12,500 per year instead of the present $9,960 and
that a doctor of medicine be appointed state health officer at the
earliest possible date.

This resolution was referred to the Committee on
Resolutions for consideration.

At this time, the chair presented Mrs. J. D. Cardy,
president of the Woman’s Auxiliary, who presented her
report.

REPORT OF THE PRESIDENT OF THE
WOMAN'S AUXILIARY

It is indeed an honor and a privilege to appear here
and present the accomplishments of our state auxiliary.
I bring you greetings from physicians’ wives in every
corner of our state, wives who are dedicated to the med-
ical profession and the ideals for which it stands.

During the past year, in accordance with the policy
of our national organization, the presidents of our 10
component districts and I have stressed 4 topics: legis-
lation, Today's Health, A.M.E.F., and a closer relation-
ship with our district and state societies. I will discuss
these activities in more detail.

In the field of legislation, we presented to onr mem-
bers various bills under consideration in Washington.
We have been particularly concerned with the Forand
bill and the effect its passage would have on the prac-
tice of medicine as we know it today. My visits to the
district auxiliaries afforded the opportunity to point out
the dangers of this bill, as well as the damage caused in
the last few years by sneak bills which have expanded
the provisions of the Social Security Act and jeopardized
the practice of free medicine.

To further increase the knowledge and interest of our
members in matters of health legislation, two articles
dealing with the subject were published in our state
paper, News, Views, and Cues.

Our “key women” in legislation attended both the
North Central Medical Conference at Minneapolis last
November and the special legislation committee meeting
at Bismarck in March. At this meeting, plans were made
for combating the Forand bill.

In this area of congressional activity so vital to all of
us, our members are well informed and we stand ready
to give you our assistance.

Concerning Today’s Health, we emphasize the impor-
tance of placing in the hands of the public a magazine
in which the articles on medicine are written by experts
in the field. We have used posters, letters, and slides for
special projects to promote sales of this publication.
I believe it would be to the interest of all of us to en-
courage a wider circulation and reader acceptance of
Todays’ Health.

The A.M.E.F. has received much of our attention and
its founding, growth and purpose were outlined in my
talks. A “Daily News” from the A.M.A. convention last
June was used with effect. This particular copy showed
the presentation of a huge contribution to the A.M.E.F.
from the Illinois State Medical Association and helped to
impress our members with the tremendous importance
of the foundation. This year, by the use of memorial
cards and by direct contributions, we will turn over more
than $200 to the A.M.E.F.

In 1950, when we considered establishing our Sopho-
more Medical Student Loan Fund, we looked to the
state medical association for authority, guidance, and
assistance. This we received in full measure, and, since
then, I am sure you have become more and more cog-

410

TIIE JOURNAL-LANCET

nizant of our sincere desire to be of assistance to you.
I wish to thank your officers, your committee chairmen,
and vour executive secretary for the invaluable assist-
ance they have given the state and district auxiliaries.

Also, we wish to extend our thanks to the state med-
ical asosciation for its support in the American Associa-
tion of Physicians and Surgeons essay contest. Your cash
awards to the state winners encouraged 6 of our districts
to seek the permission of their local societies to promote
this project. It is felt that this activity will do much
to better our public relations.

At its fall meeting, our Board voted to support the
North Dakota Cancer Society and its Cancer Caravan.
In these and other activities too numerous to mention,
you will find that our members are constantly active in
the field of public relations.

Safety is a relatively new division in the program of
our national auxiliary, and our participation at state and
district levels has been rather limited. In April, I repre-
sented our organization at President Eisenhower’s Con-
ference on Traffic Safety. This was a very profitable ex-
perience and one I shall long remember. Throughout our
entire country, traffic safety has become a most vital
problem. I am certain our group can play an important
part in this program and consideration of this topic will
be included in the proceedings of this convention.

Our Medical Student Loan Fund is still our major
project. Early this year, we received a wonderful letter
from President George W. Starcher of the University.
Dr. Starcher praised and thanked our members for their
wonderful contribution to medical education in North
Dakota. He also asked our continued support and pointed
out the ever increasing need for a loan fund such as
ours. It was feared that the passage of a bill providing
loans from the Medical Center Fund would tarnish our
pioneer project. Such has not proved to be the case.
During the past year, so many applications were made
for our maximum loan of $1,000 that they could not
be met. Individual loans of only $500 could be granted.

In districts where our members are few in number,
individual contributions are made to the fund. In our
larger districts, money is raised by projects, such as
luncheons, rummage sales, style shows, dinner dances,
used book sales, and ticket sales on floral center pieces
used at district auxiliary dinner meetings.

To date over $14,000 has been raised and assistance
has been given to 25 medical students. The sum af
$2,604.42 is on hand for loans this year.

Gentlemen, as you know, in your day, few medical
students were married and the need for financial support
was not so great. However, since it is a trend of the
times we feel that we are the logical group to which our
young doctors of tomorrow should make their appeal
for assistance. I should like to ask you to encourage
your wives to increase their already wonderful endeavors
in this field.

Now, I should like to bring to your attention the or-
ganization and progress of a young group important to
all of us. In 1952, our state president and representatives
of the Grand Forks District Auxiliary met the medical
students’ wives of our University. On this occasion, the
Medical Student Wives Club was formed. Since its in-
ception, this group has shown enthusiasm and interest
and has a perfect record of membership. Close contact
between the club and our Grand Forks Auxiliary is being
maintained. Auxiliary members open their homes for one
of the student wives’ meetings each month. Also, an aux-
iliary member is appointed as advisor to them. Each
year, usually during the visit of our state president, the

girls are guests at a Grand Forks Auxiliary dinner meet-
ing. This group, in turn, entertains the auxiliary at a
coffee party. Furthermore, they have chosen to submit
an annual report.

This very day, the Medical Student Wives Club of
North Dakota will be among the first in the nation to
receive its charter as an auxiliary to the Student Ameri-
can Medical Association. This presentation is taking place
in Chicago at the first convention of the auxiliary to the
Student American Medical Association.

We are deeply grateful to our publicity chairman and
editor, since, through their efforts, 4 outstanding editions
of News, Views unci Cues were sent to us this year.
Articles contributed by many of our state chairmen,
President Starcher’s letter, profile sketches, and news
of all our districts were in each issue. They also prepared
and sent news releases to all our state newspapers.

While I believe the topics I have just discussed are
of greatest interest and importance to our auxiliary and
to you, there are several other activities that are of great
significance and worth mention. In almost all our dis-
tricts, at least 1 program of the year has been devoted
to Mental Health, and the Committee on Mental Health
has been able to distribute valuable information to our
members. Programs of civil defense play a role in at
least 5 of our districts, and we can expect further expan-
sion of tins activity with the organization of more civil
defense units. Our recruitment program has continued
much the same as last year and includes all allied med-
ical careers.

The Women’s Auxiliary to the North Dakota State
Medical Association is not a social group. It is a com-
munity service group, and its desire is to continue and
better its work. We consider it an honor to work with
you and for you. Please call on your auxiliary.

Speaker Dodds thanked Mrs. Cardy and called for
any further new business.

Dr. C. M. Lund at this time presented the following
resolution:

RESOLUTION

Whereas, a program of establishing cancer registries in North
Dakota hospitals has been approved by staff members of most hos-
pitals, and

Whereas, cancer registries have now been established in 15 hos-
pitals and a sound program of establishing many more in the
future appears to be certain, and

Whereas, cancer registries are required by the American College
of Surgeons for hospital accreditation and evidently will be a re-
quirement of most hospital associations for accreditation.

Now, therefore, be it resolved that the North Dakota Medical
Association recommend the establishment of a central cancer regis-
try to be established and maintained at no expense to the North
Dakota State Medical Association and be located and maintained
by the Bureau of Vital Statistics of the United States Public
Health in Bismarck.

This resolution was referred to the Committee on
Resolutions.

Adjournment

There being no further new business to come before
the House, it was moved and seconded that the first ses-
sion of the House of Delegates adjourn to reconvene at
2:00 p.m., Sunday, May 4, 1958. Time of adjournment
was 5:30 p.m.

PROCEEDINGS OF THE HOUSE OF DELEGATES
of the North Dakota State Medical Association
Seventy-First Annual Meeting, Second Session
Minot, North Dakota, May 4, 1958

The second session of the House of Delegates was
called to order by Speaker Dodds at 2:00 p.m.. May 4,
1958, at the Clarence Parker Hotel, Minot. The chair-

SEPTEMBER 1958

411

man of the Credentials Committee, Dr. John Gillam,
reported that there was a quorum present. Secretary
Boertli called the roll and the following delegates re-
sponded :

Drs. A. C. Burt, Fargo; F. M. Melton, Fargo; W. L. Macaulay,
Fargo; F. A. DeCesare, Fargo; John S. Gillam, Fargo; E. J. Bei-
thon, Wahpeton; D. G. Jaehning, Wahpeton; R. M. Fawcett Dev-
ils Lake; J. H. Mahoney, alternate; Devils Lake; Robert. Painter,
Grand Forks; G. L. Countryman, Grafton; R. E. Mahowald, alter-
nate, Grand Forks; W. P. Teevens, Grafton; Wellde Frey, alter-
nate, Drayton; V. J. Fischer, Minot; A. R. Sorenson, Minot; F. D.
Naegeli, Minot; A. F. Hammargren, Harvey; C. J. Klein, alternate.
Valley City; R. W. Henderson, Bismarck; Milton Nugent, Bis-
marck; R. B. Tudor, Bismarck; Carl Baumgartner, Bismarck; Ed-
mund Vinje, Hazen; T. E. Pederson, Jamestown; John van der
Linde, Jamestown; A. K. Johnson, Williston; Keith Foster, Dickin-
son; and R. W. McLean, Hillsboro.

There were 29 delegates present. The following also
attended the meeting:

Drs. R. H. Waldsehmidt, L. W. Larson, C. M. Lund, K. G.
Vandergon, J. C. Fawcett, C. J. Glaspel, C. H. Peters, O. A
Sedlak, R W. Rodgers, Amos Gilsdorf, G. W. Toomey, V. G. Bor-
land, N. A. Youngs, D. J. Halliday, R. D. Nierling, John Craven,
and Mr. Lyle A. Limond.

The first order of business was a motion to dispense
with tlie reading of the minutes of the first session. Mo-
tion was seconded and passed.

The Chair, at this time, digressed from the usual order
of business to yield the floor to Dr. II. M. Berg, who
presented the following information concerning the status
of the State Tuberculosis Sanatorium.

“As the council felt this was too big a matter for them
to decide, a committee was appointed consisting of Dr.
G. A. Dodds, Dr. Joseph Sorkness, and myself. We went
over the letter from Herman H. Joos, chairman of the
Board of Administration, regarding the situation of the
North Dakota Tuberculosis Sanatorium and came to the
following conclusions for the House of Delegates:

“The committee recommends the following:

“1. Every effort be made to keep the North Dakota
Tuberculosis Sanatorium in operation.

“2. A vigorous attempt be made to find a competent
replacement for Dr. Loeb.

“3. An advisory committee of 3 members of the North
Dakota State Medical Association be established to advise
the superintendent of San Haven and/or the North Da-
kota State Board of Administration on the medical ad-
ministration of the tuberculosis sanatorium. The mem-
bers of this committee should be selected by the presi-
dent of the North Dakota State Medical Association and
their names submitted to the chairman of the Board of
Administration for appointment. This committee would
meet at least every three months and at other times as
requested by the superintendent, the chairman of the
Board of Administration, or the advisory committee.

“4. That the names for this committee be submitted
immediately, since the superintendent of the sanatorium
has resigned effective July 1, 1958, and this committee
should assist the Board of Administration in obtaining a
replacement.”

G. A. Dodds, M.D.

Joseph Sorkness, M.D.

IT M. Berg, M.D.

This presentation was followed by a request from
Speaker Dodds for comments from the delegates. An
informal discussion followed, resulting in a motion made
by Dr. Mahowald and seconded by Dr. Tudor that the
recommendations from the committee be approved.
Motion passed.

REPORTS OF REFERENCE COMMITTEES

Reference Committee to Consider the Reports of the
President. Secretary, Executive Secretary, and Treasurer

Dr. J. H. Mahoney, chairman, presented the following

THE JOURNAL-LANCET

reports and their discussions, which were adopted sec-
tion by section and as a whole:

1. Report of the President. The reference committee
concurs with the president that the general membership
is too apathetic and has too little knowledge of the af-
fairs of our state association. All district societies should
receive reports of the transactions at the annual meeting,
and we delegates have the responsibility of infusing the
enthusiasm of our state officers to the district member-
ship.

We are pleased to note the president’s reference to
the Liaison Committee in respect to Blue Shield. The
association is now officially represented on the Board of
Directors of Blue Shield. We believe that this representa-
tion will insure proper division of coverage of these plans.
This committee does not believe that the House of Dele-
gates is the proper vehicle to approve Blue Shield sched-
ules, except as noted previously.

We recommend the innovation for selecting committee
members as introduced this past year by Dr. Rodgers.

We concur with the president that the defeat of the
Forand bill is of utmost importance.

The president has emphasized our duty in the care of
the tubercular patient. As long as tubercular patients
live, the epidemic potential is present.

The reference committee concurs with the president’s
recommendation that the elective officers should be given
more responsibility, and perhaps their duties should be
definitely outlined. We believe the Committee on Con-
stitution and Bylaws should be directed to evaluate the
duties of state officers so that the president-elect and the
vice-presidents could be utilized in a more efficient man-
ner.

This committee feels that Dr. Rodgers has exemplified
the leadership which medicine so desperately needs. He
shoidd be commended for the initiative he has demon-
strated. His interests have been broad, yet, no detail has
escaped his attention.

This portion of the report was adopted.

2. Report of the Secretarij. The reference committee
reviewed the report of the secretary. Dr. E. H. Boerth,
and notes that he re-emphasizes the importance of col-
lecting the dues and forwarding them to the state office
not later than March I of the current year. We wish to
call the House of Delegates’ attention to his report, which
shows only 313 paid-up members as of April 15, 1958,
in comparison to 395 paid memberships in 1957. We
urge each district to increase its efforts to submit the
dues promptly.

This portion of the report was adopted.

3. Report of the Executive Secretarij. The reference
committee believes, as does the executive secretary, Mr.
Limond, that committees should function actively. The
association has felt there is a need for these committees
and has created them. Developing affirmative construc-
tive programs can be stimulating to the committees as
well as the association.

Next year is legislative year. We recommend that the
district societies have active legislative committees ready
to function and that they personally know their local
legislators.

We commend our executive secretary in performing
his functions and duties.

This portion of the report was adopted.

4. Report of the Treasurer. The reference committee
studied the report of the treasurer. Dr. E. J. Larson, and
we wish to commend him for his financial astuteness and
managment of the association’s funds.

This portion of the report was adopted.

The motion was made by Dr. Mahoney and seconded

412

by Dr. Bcithon that the report be adopted as a whole.
Motion was carried.

J. H. Mahoney, M.D., Chairman
Fred Erenfeld, M.D. (not present)
A. K. Johnson, M. D.

Milton Nugent, M.D.

VVellde Frey, M.D.

Reference Committee to Consider the Reports of the Council,
Councillors, and Special Committees

Dr. R. M. Fawcett, chairman, presented the following
reports and their discussions, which were adopted sec-
tion by section and as a whole.

1. Report of the Chairman of the Council. Your ref-
erence committee reviewed the report of the chairman of
the council. We recommend that our delegate to the 1961
annual meeting of the A.M.A. issue an invitation to the
then selected president-elect to address our Diamond
[ubilee Meeting in 1962.

Your reference committee noted that the council,
through its chairman, recommended to the State Welfare
Board that a joint meeting be held between the State
Welfare Board Committee on Crippled Children and the
State Association Committee on Crippled Children. There
is no indication that such a meeting has been held. Your
committee recommends that a report relative to this be
presented on the floor of the House of Delegates. If no
such meeting was held, we recommend that it be held
during the ensuing year and the results of the meeting
be reported to the doctors of the state.

This portion of the report was adopted.

Dr. E. T. Keller next spoke briefly regarding the joint
meeting between the State Welfare Board Committee on
Crippled Children and the State Association Committee
on Crippled Children. “I was your appointed delegate
to that committee in liaison with the Crippled Children’s
program. We went over all the items separately which
we felt were not items belonging to the long-term hard-
ship cases. Those 2 items were intussusception and con-
genital pyloric stenosis. I understand that later they
crossed out other items. I think it should be brought up
before the House of Delegates that they should take a
stand on either adding or keeping items. Whether this
is a trend to socialized medicine or not, I am not sure;
but I do think we should take a stand on it. I believe
this calls for discussions and deliberations.

2. Reports of the Councillors. The reference committee
reviewed the reports of the councillors. Although some
deficiencies were present, marked improvement in the
reports of the councillors was noted. Our committee
again urges the executive secretary’s office to advise each
councillor of the suggested acceptable form for submit-
ting such reports, as was pronounced by the House of
Delegates in May 1957.

This portion of the report was adopted.

3. Report of the Committee on Maternal and Child
Welfare. With reference to the paragraph: “We recom-
mend that the local county medical societies have peri-
odic polio injections every two years” — the reference
committee recommends that this portion of the report be
deleted for reasons of ambiguity.

With reference to paragraph 8, outlining minimal re-
quirements for filing adoption papers, the reference com-
mittee wishes to amend the first sentence to read: “If
sterility is the basis for adoption, the following minimal
requirements for the filing of adoption papers are:”

This portion of the report, with amendments, was
adopted.

4. Reports of the Committees on Cancer, Nursing Ed-
ucation, Mental Health, Diabetes, Geriatrics and Re-

habilitation, Emergency Medical Service, A.M.E.E.,
School Health, and the member of the Governor's Health
Planning Committee.

There being no controversial subjects in these reports,
this portion of the report was adopted after their review
by the committee.

5. Report of the Committee on Crippled Children.
The reference committee reviewed the report of the
Committee on Crippled Children and recommends that
this committee meet with the State Welfare Board Com-
mittee on Crippled Children each year to impress on
that board the continuing interest of the association in
the policies of the Crippled Children’s program.

This portion of the report was adopted.

6. Report of the Committee on Foreign Trained Phy-
sicians. The reference committee reviewed the very com-
plete report of the Committee on Foreign Trained Phy-
sicians and wishes to commend its chairman, Dr. C. [.
Glaspel, on the excellence of his report. This committee
recommends that the present standards and statutes of
the Medical Practice Act of the 1957 legislature be main-
tained.

This portion of the report was adopted.

7. Report of the Committee on Constitution and By-
laws. The reference committee reviewed the report of
the Committee on Constitution and Bvlaws and concurs
in its chairman’s recommendation that a special com-
mittee on revision of the Constitution and Bvlaws need
not be appointed annually until such a need becomes
apparent. It further commends the committee and its
chairman. Dr. Robert Radi, for their excellent work in
revising the Constitution and Bvlaws.

Speaker Dodds added the following remarks to this
report: “You will remember that in the reference com-
mittee’s report to consider the report of the president,
it was recommended that the Committee on Constitution
and Bylaws should be directed to evaluate the duties of
state officers, therefore admitting to a need for this
committee.”

This portion of the report was adopted.

Dr. R. M. Fawcett moved the adoption of the report
as a whole, seconded by Dr. Tudor, and carried.

R. M. Fawcett, M.D., Chairman

W. L. Macaulay, M.D.

Robert Gilliland, M.D.

Edmund Vinje, M.D.

V. J. Fischer, M.D.

W. P. Teevens, M.D.

Reference Committee to Consider the Reports of the
Delegate to the A.M.A., Medical Center Advisory Council,
and the Committee on Medical Education

Dr. Keith Foster, chairman of this committee, pre-
sented the following reports and their discussions, which
were adopted section by section and as a whole.

1. Report of the Committee on Medical Education.
The reference committee commends the report of Dr. H.
M. Berg and his committee and wishes to emphasize the
importance of short courses to state members of the
American Academy of General Practice. Also, it might
be well that physicians in the state consider splitting
their donations to A.M.E.F. to include a proportion to
North Dakota and thus increase the amount received bv
our University per year. We strongly recommend that a
physician should, if possible, be on the State Board of
Higher Education.

An amended report of the Committee on Medical Ed-
ucation was presented at this time, and follows: “We
suggest that the Committee on Legislation attempt to
have the legislature pass the following amendment to

SEPTEMBER 1958

413

Senate bill No. 181, which deals with loans to third and
fourth year medical students.

“Any doctor who has borrowed funds under this bill
and who returns to the state for his internship and resi-
dency or accepts a position in a state institution be al-
lowed one-fifth credit for each year so spent on the un-
paid balance of the loan and one-fifth of the accrued
interest thereon.”

H. M. Berg, M.D., Chairman

Committee on Medical Education

This portion of the report, with the inclusion of the
amended report, was adopted.

2. Report of the representative to the Medical Center
Advisory Council. The report of the representative was
reviewed, and the reference committee wishes to re-em-
phasize to the House of Delegates and, in turn, to the
association that the physicians of the state should show
more interest as individuals in the problems and policies
of the school and procurement of well qualified students
for North Dakota’s School of Medicine.

This portion of the report was adopted.

■3. Report of the Delegate to the A.M.A. The reference
committee wishes to compliment Dr. Wright on his re-
port as the delegate to the A.M.A. as an excellent sum-
mary of the more important actions of the A.M.A. within
the past year. Also, it is suggested that this report in
the Handbook be read by the delegates to the individual
district societies to further enlighten individual members.

This portion of the report was adopted.

Dr. Foster moved the adoption of the report as a
whole. Motion was seconded bv Dr. Pederson and carried.

Keith Foster, M.D., Chairman

R. B. Tudor, M.D.

R. W. McLean, M.D.

R. E. Mahowald, M.D.

J. S. Gillam, M.D.

Reference Commilfee to Consider the Reports of
the Standing Committees

Dr. Hammargren, chairman, presented the following
reports and their discussions, which were adopted section
by section and as a whole.

1. Report of the Committee on Necrology and Med-
ical History. It was with a feeling of sadness and sorrow
that the reference committee reviewed the report of this
committee. As it must to all men, death has come dur-
ing the past year to 7 of our esteemed and beloved
brother physicians. They are, namely: Dr. W. W. Wood,
Jamestown; Dr. H. M. Waldren, Jr., Drayton; Dr. A. E.
Donker, Carrington; Dr. W. H. Gilsdorf, Valley City;
Dr. K. M. Murray, Scranton; Dr. |. G. Lamont, Grafton;
and Dr. E. S. O’Hare, Esmond.

These doctors have all been a credit to our profession,
and some have been very active in this association and
have done a great deal to promote its best interests. Dr.
Hammargren asked the delegates to manifest their rev-
erence and respect by standing in a moment of silence.

Moment of silence adopted this portion of the report.

2. Report of the Committee on Legislation. The ref-
erence committee noted that the Committee on Legisla-
tion had not had any special meeting as of March 18,
1958, since there was no legislative session in North Da-
kota this year. The chairman of the Legislation Commit-
tee commented on the Forand bill especially, warning
that if passed this woidd be a rather rapid step toward
full socialization. He also commented on the Jenkins-
Keogh bill, and we wish to read this paragraph to the
House of Delegates. “Another bill that is to again be
considered within this next Congress (the Jenkins-Keogh

bill), is a bill granting the privilege to the physician of
setting aside a certain percentage of his earnings for re-
tirement. This is done in view of the fact that the physi-
cian is not included in social security. The physician has
not been included in social security because of his desire
to be left on the outside, and I am in accord with such
decision. It is the impression and opinion of your chair-
man that, should we accept any privileges including so-
cial security, we would simply be advancing ourselves
one step closer to socialized medicine and condoning so-
cialized medicine.”

This portion of the report was adopted.

3. Report of the Committee on Public Relations. The
reference committee reviewed the report of this com-
mittee and wishes to commend the committee for their
activity in the field of public relations.

This portion of the report was adopted.

4. Report of the Committee on Official Publication.
The reference committee notes that the Committee on
Official Publication reports that the contract with The
Journal-Lancet has two more years to run.

This portion of the report was adopted.

5. Report of the Committee on Public Health. The
reference committee reviewed the report of the Commit-
tee on Public Health and notes that they held a meeting
on September 22, 1957. The purpose of this meeting was
to discuss the Asian Hu problem, and they recommended
the vaccine.

The committee also noted that only 55 per cent of
the population of North Dakota had received the first
polio injection as of February 28, 1958; only 48.8 per
cent had received the second injection; and 32.6 per
cent had had the third injection.

The venereal disease incidence of the state was also
noted.

This portion of the report was adopted.

Dr. Hammargren, chairman of the committee, moved
that the report as a whole be adopted. Motion was sec-
onded by Dr. Sorenson and carried.

A. F. Hammargren, M.D., Chairman

A. R. Sorenson, M.D.

G. L. Countryman, M.D.

E. [. Beithon, M.D.

John Van der Linde, M.D.

Reference Committee to Consider the Reports of the
Committee on Medical Economics, Committee on Prepayment

Medical Care, Committee on Veterans Medical Service
and Committee on Rural Health

Dr. Carl Baumgartner, chairman, presented the fol-
lowing reports and their discussions, which were adopted
section by section and as a whole.

1. Committee on Medical Economics. The reference
committee reviewed the report of the Committee on
Medical Economics and is cognizant of the fact that the
commttee has been exceptionally active this past year in
bringing to a head many problems that have confronted
us in the past.

a. Through their efforts, the group plan of life insur-
ance for members of the association has been made avail-
able at moderate premium rate savings without evidence
of insurability.

b. In regard to welfare payments, the Committee on
Medical Economics feels that the House of Delegates of
the North Dakota State Medical Association should seri-
ously consider urging the A.M.A. to make efforts to have
Congress amend the present Social Security Act, which
makes payment of physician services to the recipient in-
stead of the physician — the amendment thus requiring
direct payment to the physician for his services. It is

414

THE JOURNAL-LANCET

evident that many a recipient fails to use this added fund
for the payment of the doctor.

Your reference committee concurs witli the Committee
on Medical Economics regarding vendor payments to the
doctor rather than the recipient, and we recommend that
our delegate to the A.M.A., Doctor Wright, so convey
this recommendation to the House of Delegates of the
A.M.A.

c. It is noted that the Committee on Medical Econom-
ics has endeavored to draw up a relative value fee sched-
ule for the entire state from which other schedules, such
as Workmen’s Compensation, Welfare Board, and others,
could be taken. Such an accomplishment is a stride for-
ward toward setting up a fee schedule to these various
component organizations acceptable to the physicians of
this association. We feel also that it must be kept in
mind that such a relative value schedule with its conver-
sion factors should not become the property of the vari-
ous agencies.

Your reference committee, however, feels that there is
a rather wide variation between the conversion factors
of Welfare Schedules and Workmen’s Compensation
Schedules. We, therefore, feel that the negotiating com-
mittee be given more flexible authority to change these
conversion factors in keeping with the present day fee
schedules as dictated by economic situations and relative
to the various agencies with whom the negotiating com-
mittee confers. With this in mind, your reference com-
mittee feels that such a relative value fee schedule be
adopted and that the House of Delegates go on record
stating that all fee schedules involving members of the
North Dakota State Medical Association be approved by
the Association and that no changes be made in these
schedules without mutual consent of the parties involved.

The reference committee recommends that the repre-
sentatives of the specialty groups review the relative
value schedule and recommend to the Committee on
Medical Economics any changes they feel necessary.
This should be done in the immediate future in order
that the Committee on Medical Economics has this in-
formation and can negotiate a relative value schedule
with the various agencies whose budget for the next two
years will be established this fall.

This reference committee recommends that the con-
tract which has been submitted in the Indian health area
office should not be signed until the relative value sched-
ule has been adopted and the contract negotiated on this
basis.

This portion of the report was adopted.

In connection with the first part of this report in
regard to vendor payments, Dr. Boerth next read a letter
from the senior senator in Washington, D.C.

United States Senate
April 28, 1958

Dear Dr. Boerth:

Mr. Carlyle Onsrud has written to me concerning H.R. 11703,

bringing to my attention the fact that your organization is anxious
to see that this legislation gets passed.

This is just a note to let you know that I am 100 per cent with
you on this hill, and I will do everything I can to see that it
gets early favorable action. I have already notified Congressman
McCormack that 1 am supporting the hill, and 1 will do all I can
to get the other senators along with me on this.

If there is any other way in which I may be of service to you
down here, he sure to let me know. I am anxious to help when-
ever possible.

With just every good wish and kindest regards, I am,

Sincerely,

William Lancer

This portion of the report was adopted.

2. Committee on Prepayment Medical Care. The ref-
erence committee is cognizant of the fact that the Com-
mitte on Prepayment Medical Care and the Committee
on Medical Economics have overlapped in recent years
and notes that the Committee on Prepayment Medical
Care has been abolished in the new Constitution and
Bylaws. In the past, this committee was set up to work
with and aid the development of Blue Shield and Blue
Cross. This committee’s function is now defunct, since
its purpose has been accomplished.

This reference committee notes that mention is made
in the report of the Committee on Medical Economics
regarding Medicare. It is noted that our representing
committee fared well in Washington in maintaining our
previous schedule and thus preserved the practice of
medicine in this state along the lines that we have en-
joyed in the past. Your reference committee, therefore,
commends Dr. Rodgers, Dr. Peters, and Mr. Limond for
their untiring and thoughtful efforts in negotiating with
the Department of the Army in Washington in January
of this year.

This report, in the future, will be included in the
report of the Committee on Medical Economics.

This portion of the report was adopted.

■3. Committee on Rural Health. Your reference com-
mittee notes that the Committee on Rural Health did not
function in the past year, but it is our hope that all
of us in our own way are cognizant of our own local
needs in Rural Health and exploit them to the best of
our individual ability.

This portion of the report was adopted.

4. Committee on Veterans Medical Service. Your ref-
erence committee notes that there was no need for the
Committee on Veterans Medical Service to function this
past year, since no problems have arisen.

This portion of the report was adopted.

Dr. Baumgartner moved that the report as a whole be
adopted. Motion was seconded by Dr. Foster and car-
ried.

Carl Baumgartner, M.D., Chairman

Arthur C. Burt, M.D.

G. Christianson, M.D.

Frank Melton, M.D.

(TO BE CONTINUED IN OCTOBER)

SEPTEMBER 1958

415

A History of Public Health, by
George Rosen, M.D., 1958. New
York: M.D. Publications, Inc., 551
pages. $5.75.

This book describes the develop-
ment of public health, beginning in
the Greco-Roman world and taking
the reader through the Middle Ages
(500 to 1500 A.D. ), the eras of
1500 to 1750, 1750 to 1830, the
Industrial and Sanitary Movement
(1830 to 1875), and the bacterio-
logical era and its aftermath. But,
this book is something more; the
author portrays to some extent the
social, political, and economic prob-
lems in each of these periods and
the influence which these problems
have had upon our concept of the
relationship between man and his
environment and between the in-
dividual and services provided by
government on an organized com-
munity basis. This book provides a
wealth of information for the health
worker interested in the broad field
of public health or in a number of
special fields of interest, for example,
environmental sanitation, epidemiol-
ogy, occupational health, statistics,
public health education, public health
nursing, nutrition, and maternal and
child health. Included also are des-
criptions of the development of hos-
pital care and of various efforts
made to date to tackle the knotty
problem of medical care of the
people. To provide such a compre-
hensive treatment of such a varied
field requires a broad background
and knowledge which the author
skillfully demonstrates.

The book is interesting and well
written. The preface especially de-
serves a word of praise because it
gives the reader a much needed per-
spective of the point from which we
have come and of the place where
we currently are.

This book is easily read and can
be recommended for the public
health worker, students, and the lay
public.

Helen M. Wallace, M.D.

•

Psychobiology, by Adolf Meyer,
M.D., Late Henry Phipps profes-
sor of psychiatry, The Johns Hop-
kins University, Baltimore, Mary-
land, 1957. Springfield, Illinois:
Charles C Thomas, 258 pages.
$6.50.

This book consists of three lectures
given in April 1932 by Dr. Adolf
Meyer for the Thomas William Sal-
mon Memorial lectures at the New
York Academy of Medicine. The
publication of these lectures was

416 THE JOURNAL-LANCET

delayed twenty-five years, during
which time many elaborations and
revisions were made.

The lectures represent an effort on
Dr. Meyer’s part to bring his con-
ception of man into a closer relation-
ship with the other disciplines of
science and medicine. He desired to
work up to a balanced and socialized
conception of medicine and life
rather than a dogmatic one, to a
consciousness of psychiatry in its
truly medical sense and to let this
work take a concrete form as an
expression of investigation rather
than philosophy.

In the first lecture, he seeks to
affirm for science the naturalness
and objectivity of man’s life as a
person. Because of his broad insight,
he has been able to understand the
nature and course of man’s develop-
ment. The reader catches glimpses
of the effects and of the forces ot
adaptation in the history of man.
The author attempts to show how
the psychobiologic neurotic patient
presents a picture of man and life
which can satisfy our critical com-
mon sense.

In the second lecture, one is im-
pressed with his dominant preoc-
cupation with the symbolization. He
obviously felt that an understanding
of his dynamic conception of psycho-
pathology depended on a thorough
grasp of the mind as a symbolizing
function. His presentation of pa-
thology is fundamentally an issue
of control.

In the third lecture on therapy,
Dr. Meyer stresses the point that
the fundamental responsibility of the
physician is to change the patient.
He believes that psychobiologically
oriented psychiatry bases its treat-
ment on the principle that the assets
of the patient, understood by the
phvscian, can be used to counteract
the less healthy tendencies. There
are no rules of the thumb. Treat-
ment consists chiefly in defining
one’s own position with respect to
the patient’s story, defining the pa-
tient’s position with respect to it,
and working the most melioristie

approximation of these two view-
points.

I feel this book would be most
interesting and thought provoking
to any practitioner of medicine, es-
pecially to those particularly inter-
ested in the behavior of man.

Robert W. Cranston, M.D.

The Dermatologist’s Handbook, by
Ashton L. Welsh, M.D., edited
by Arthur C. Curtis, M.D., 1957.
No. 293, American Lecture Series,
monograph in Bannerstone Divi-
sion of American Lectures in Der-
matology. Springfield, Illinois:
Charles C Thomas; Oxford: Black-
well Scientific Publications, Ltd.;
Toronto: Ryerson Press, 427 pages.
$15.00.

This rather large volume is essential-
ly a compilation of a considerable
amount of data on a great number
of pharmaceutic and biologic pro-
ducts which are used both internally
and topically. The information has
been obtained from the United States
Pharmacopoeia, National Formulary,
New and Nonofficial Remedies, and
from the various manufacturers.

In the first portion of the book,
various topical dermatologic pre-
parations are listed, including pro-
prietary agents as well as many
prescriptions. These are all grouped
according to therapeutic usefulness.
A variety of mucous membrane med-
ications are also included in this
section. Brief mention is made of
mechanical therapeutic measures,
diagnostic tests, and allergens.

The next section deals with in-
ternal therapy and includes descrip-
tive information, indications and
contraindications, methods of ad-
ministration, dosages, and reactions
of a large number of biologic and
pharmaceutic products.

The last section contains general
and specific reference data, includ-
ing tables of normal values, infor-
mation on the removal of stains,
prescription writing, and, finally,
chapters on reactions to various ther-
apeutic substances.

As the name implies, this book has
presumably been prepared for use
as a handbook by dermatologists.
However, some of the information
seems of doubtful value to most der-
matologists and the omission of this
material would enhance the value
of the book. Nevertheless, it does
contain a vast amount of pharmaco-
logic data and should be useful as
a reference book.

Elmer M. Hill, M.D.

SERVING THE MEDICAL PROFESSION OF MINNESOTA.
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

The Apparent Relationship Between
the Stein-Leventhal Syndrome
and Endometrial Carcinoma

JOSEPH SORENESS, M.D., JOHN A. SWENSON, M.D., and
ROBERT E. LUCY, M.D.

Jamestown, North Dakota

During the past twenty years, much has
been written and discussed concerning the
so-called Stein-Leventhal syndrome. Appearing
in the literature throughout the world have been
many reports of single cases1-13 and several re-
ports of series of varying lengths. 14-111 However,
not until recently has any emphasis been placed
upon the apparent relationship existing between
the Stein-Leventhal syndrome and endometrial
carcinoma, which occurs as a late manifestation
of this syndrome.

REVIEW OF LITERATURE

In 1935, Stein and Leventhal14 presented the first
report of this new syndrome, consisting of men-
strual irregularity, a history of sterility, hirsut-
ism, and obesity; amenorrhea was usually noted
and, occasionally, retarded breast development.
They postulated that the polycystic ovarian al-
terations noted were related to an abnormal
pituitary hormonal stimulation with the forma-
tion of capsular fibrosis of the ovaries, which
acted as a direct barrier to ovulation. Bailey,11
in 1937, determined its cause to be a deficiency
of pituitary stimulation resulting in secondary
cessation of ovarian physiology; the arrest of fol-

JOSEPH SORKNESS, JOHN A. SWENSON, and ROBERT E.

lucy are associated with the DePuy-Sorkness Cdinic
in Jamestown, North Dakota.

lieular maturation led to the polycystic ovarian
condition and perhaps also to chronic cirrhosis
of the peripheral tunic and central stroma. In
a later report, Ingersoll and McDermott16 ob-
tained normal values for the follicular stimulat-
ing hormone in 3 of 29 patients studied and the-
orized that the pituitary deficiency was in a lu-
teinizing factor. Sommers and Wademan20 con-
tended that pituitary basophilism interfered with
the production of follicle stimulating hormone.
DuToit21 stated that the thickened ovarian cap-
sule was secondary to the formation of cysts and
was related to the absence or defective develop-
ment of the thecal core. Still other investigat-
ors22— 24 ]iave ascribed the alterations in the ovary
to circulatory changes in the ovary.

It is readily observed that, while there is much
interest in this syndrome and much study has
been done concerning its etiology and its phys-
iology, agreement does not exist on these points.

A considerable degree of unanimity is found
in the literature regarding the actual gross
pathology involved, however. Gross ovarian
changes consisting of enlargement, grey-white
color, and a thick fibrous layer which covers a
rim of immature follicles and overlies a fibrous
central core containing no cysts are common
findings.61416'2’’-27 Other features of the syn-
drome do not occur uniformly in each patient.
Hirsutism, retarded breast development, or

amenorrhea are not always present; in some
cases, hvpermenorrhea has been reported and,
in still others, sterility apparently was not a prob-
lem. Most of the reports, however, indicate the
presence of all or a majority of the usual signs
of the syndrome.

Preferred therapy has apparently been fairly
well established; most of the reports advocate
the use of bilateral wedge resection of the ova-
ries, and this procedure apparently has proved
to be successful. Van Wagenen and Morse28 have
shown by experiments that resection of one-third
of the ovarian cortex does not deplete the ovari-
an function. Agreement as to why this procedure
gives relief has not been reached. Novak and
Reycraft29 proposed that the success of the
wedge resection is due to the reduction of target
area in the ovaries, thus promoting a better pitui-
tary ovarian hormonal balance; this view was
also held by others.141’’ Hirsch30 and Jacobsen31
both favor the theory that success of the wedge
resection is due to the relief of ovarian pressure
which improves the venous and arterial blood
supplies of the follicles in the state of arrested
maturation.

Not until recently has emphasis been placed
on the relationship between the Stein-Leventhal
sydrome and the endometrial carcinoma implied
by the occurrence of the latter as a late manifes-
tation of this syndrome. In 1951, Dockertv, Love-
lady, and Foust17 presented a report in which
they stated that almost 20 per cent of women
less than 40 years of age with carcinoma of the
uterus gave clinical evidence of the Stein-Leven-
thal syndrome. They reported 1,694 patients with
carcinoma of the bodv of the uterus; of these
patients, 36 were less than 40 years of age and
7 of these had the Stein-Leventhal syndrome. Of
the 26 adenocarcinomas diagnosed, 13 were
grade I. Later in the same year, Dockertv and
Mussey32 emphasized that granulosa cell tumors
of the ovary were carcinogenic with regard to
the endometrium and reported an incidence of
16 cases which were associated with uterine ma-
lignancy.

The explanation of the association between
the granulosa cell tumor and the ovary in the
Stein-Leventhal syndrome was not clarified until
1957 when Jackson and Dockertv18 postulated
that the hyperplastic theca interna of the ovaries
in patients, through elaboration of excess estro-
gen or continual estrogenic stimulation of the
endometrium, has the same effect as the granu-
losa cell tumor. This paper presented a report
of 43 patients exhibiting the Stein-Leventhal syn-
drome seen at the Mayo Clinic from 1909 to
1954. Of these patients, 16 also had uterine car-

cinomas — 12 being adenocarcinomas and 8 ad-
enocarcinomas grade I. The carcinomas were dif-
fuse in 4 of the patients; circumscribed malig-
nant ademonas were reported in all the rest.
Age of patients ranged from 27 to 48 years, the
majority of patients being in their late 30’s and
40’s. A history of abnormal bleeding was elicited
in 14 of the 16 patients, and only 1 viable off-
spring had been delivered.

Sommers, Hertig, and Bengloff27 reported on
16 patients between the ages of 19 and 35 with
endometrial carcinoma. Menorrhagia, sterility,
amenorrhea, and obesity were frequently ob-
served in this group. Cortical fibrosis with cysts
of the ovaries, which resembled the Stein-Leven-
thal syndrome, was noted in 4 of these patients.
The ovarian changes suggested that the anterior
pituitary gland, adrenal cortex, and ovary were
all participating in hormonal imbalances. The
possible importance of estrogen as a carcino-
genic agent had been reported as early as 1939
by Dockertv and MacCarty.33 Further work in
the study of estrogenic influence in carcinoma
of the body of the uterus was presented by
Speert.34 He noted a high incidence of uterine
fundal carcinoma among women with cirrhosis
of the liver, suggesting that there was a loss of
estrogen breakdown in such women and that this
acted as an indirect cause for the high estrogen
level producing the carcinoma. In the report of
Dockertv and Mussey,32 16 cases of granulosa
cell tumors of the ovary were presented in which
associated uterine malignancy was found. Dock-
ertv and Mussey32 cite the work of Greene35
who observed a high incidence of metastasizing
fundal carcinoma in old multiparous rabbits
whose livers had been markedly impaired by
repeated attacks of toxemia of pregnancy. Es-
trogen breakdown in the liver did not occur,
giving indirect cause for a high estrogen level.
They32 also cite the work of Banner and Dock-
erty,36 and Herrell37 who together presented a
total of 87 cases of granulosa and theca cell tu-
mors of the ovaries. Uterine carcinoma was re-
ported in 15 of these cases; 3 had associated
mammary carcinoma. The latter report also
noted that uterine as well as mammary carcino-
ma was rarely observed following oophorectomy
even though the adrenals still supply a small
amount of estrogen.

CASE STUDY

During the past year, we have observed 2 veri-
fied cases of the Stein-Leventhal syndrome — a
19-year-old girl and a 37-year-old woman. The
latter subsequently developed endometrial car-
cinoma. The following report is of the latter case.

418

THE JOURNAL-LANCET

This 37-year-old schoolteacher and housewife
was first seen at the Clinic on May 23, 1957, with
the complaint of amenorrhea since March 25,
1957. Her menstrual history disclosed that her
periods had been irregular since onset of men-
struation when she was in high school. Length
of time between periods had varied from six
weeks to three months, and the average duration
of flow was seven days. She apparently had no
difficulty in becoming pregnant and had borne
2 children, now 9 and 5 years of age. For the
past three or four years, she had noticed exces-
sive growth of hair on her face, upper legs, chest,
lower abdomen, and pubic area, and she found
it necessary to shave her chin at least every
other day. No lowering of the voice or breast
atrophy had occurred, and her facial contour
was normal; there was no thyroid enlargement.
The remainder of the physical examination was
essentially normal. No shoulder hump or girdle
obesity was noted, and routine laboratory exam-
ination yielded essentially normal findings, ex-
cept for basal metabolic rate of — 16, which was
felt to be unreliable because of complete lack
of any other signs of hypothyroidism.

She was admitted to Jamestown Hospital on
June 3, 1957. Skull and lumbosacral spine roent-
genograms were taken, both of which were nor-
mal; an intravenous urogram was also normal.
The fasting eosinophil count revealed 165 cells
per cubic millimeter. Urinary 17-ketosteroid
studies were obtained on 2 occasions and showed
levels of 26.5 and 19.2 mg. per twenty-four hours.

Retroperitoneal insufflation of air was per-
formed on June 8, 1958, in an attempt to outline
the adrenal glands. The left renal area was fairly
well outlined, but the right side was inade-
quately observed. A dilation and curettage were
done, and the tissue obtained showed endome-
trium of mixed secretory type with the endo-
metrial glands dated at about the seventeenth
day and the stroma at about the twenty-third day
of a twenty-eight day cycle; this was almost two
months after her last period. Pelvic examination
under anesthesia disclosed no abnormalities, and
both ovaries were thought to be of normal size.

The patient was admitted to the hospital for
the second time on June 17, 1957. A right sub-
costal incision was made on June 20, 1957, to
explore the region of the right adrenal gland
not properly visualized by the prior retroperi-
toneal air insufflation. The 11th rib was resected
during this procedure, and the right adrenal
gland was found to be normal in size and ap-
pearance; after a biopsy of this gland, the peri-
toneum was opened and the left kidney and ad-
renal gland were palpated and found to be of

4

normal size. The pelvis was also examined at
this time, and the ovaries were thought to be
very hard and somewhat, enlarged. This incision
was then closed, the patient was placed on her
back, and a midline incision was made. Both
ovaries were somewhat enlarged and very hard,
and a bilateral oophorectomy was performed.
Pathologically, both ovaries were described as
being hard, white, and smooth-surfaced, and nu-
merous smooth-walled serous cysts up to 7 mm.
in diameter beneath a 1-mm. fibrous layer on the
outer surface were seen. Microscopic section
showed numerous small uniformly sized follicu-
lar cysts in a single line 1 to 3 mm. below the
surface of the ovary. Extensive fibrosis was
noted in the cortex of the ovary. These findings
were felt to be compatible with the Stein-Leven-
thal syndrome by the pathologist. The biopsv of
the right adrenal gland showed no significant
gross or microscopic pathologic alterations. The
patient was discharged on June 29, 1957. The
only significant postoperative change was a di-
minished rate in the growth of hair.

In February 1958, she noticed some spotting
and, on March 19, 1958, was again hospitalized.
Dilation and curettage were performed, and a
pathologic diagnosis of malignant adenoma was
made. On April 2, 1958, a total hysterectomy
and bilateral salpingectomy were performed. The
uterus appeared grossly normal. Malignant ade-
t noma was found with nests o£- epithelium invad-
ing the stalks of glandular tissue and secondary
slight invasion of the myometrium. There was a
rupture of the epithelial basement membrane,
with atypical individual cells containing hvper-
chromatic nuclei, and invasion, at times, of the
myometrium. The pathologic diagnosis was ma-
lignant adenoma and adenomyosis. She was dis-
charged on April 9, 1958, 'and has done well
postoperatively.

COMMENT

After having reviewed a fair amount of litera-
ture on the subject of the Stein-Leventhal syn-
drome, we find that, although it has been rec-
ognized for the past twenty-two years, contro-
versy still exists as to its cause and not enough
attention has been paid to the occurrence of en-
dometrial carcinoma as a late manifestation of
this syndrome.

The proposal of Jackson and Dockerty18 that
the continuous estrogenic stimulation to the en-
dometrium from the thickened theca interna of
the ovaries in patients with Stein-Leventhal syn-
drome is the inciting agent in the ensuing car-
cinoma of the endometrium, together with the
evidence presented bv others concerning the ac-

OCTOBER 1958

419

tivity of estrogen per se from granulosa cell tu-
mors and indirectly in instances such as hepatic
cirrhosis, certainly gives one considerable food
for thought regarding the role of estrogen in the
production of carcinoma.

We have not been able to conclude whether
estrogen per se is the carcinogenic agent or
whether the hormonal imbalance in the endo-
crine system provides the basis for the sequence
of events leading to carcinoma. Filling these gaps
in our knowledge could lead to definitive therapy
or certainly to further basic research concerning
the problem of uterine carcinoma.

SUMMARY

1. The literature available to us concerning the
Stein-Leventhal syndrome has been reviewed.

2. The interesting and incompletely investi-
gated relationship between the Stein-Leventhal
syndrome and endometrial carcinoma has been
reviewed.

3. A case study in which both the Stein-Leven-
thal syndrome and endometrial carcinoma occur
is presented.

4. We add our request to those of many others
that this informative pathologic relationship be
studied more completely and intensively.

REFERENCES

1. Benson, R. C., Kolb, F. O., and Traut, H. F.: Hirsutism,

defeminization, and virilization; endocrine basis for diagnosis
and treatment. Obst. & Gynec# 5:307-319, 1955.

2. Haas, R. L., and Riley, G. M.: Polycystic ovaries and amen-
orrhea; laboratory and clinical observations. Obst. & Gynec.
5:657, 1955.

3. Schneider, R. W., Kehm, R., and Binder, M. L.: Sclerocys-
tic ovaries associated with correctable sterility and oligomen-
orrhea. Proc. Am. Federation Clin. Research 3:16-17, 1947.

4. Stein, 1. F.: Gynecography : x-ray diagnosis in gynecology.

S. Clin. North America 23:165-180, 1943.

5. Stein, I. F.: Management of bilateral polycystic ovaries.

Fertil. & Steril. 6:189-205, 1955.

6. Stein, I. F., Cohen, M. R., and Elson, R.: Results of bi-

lateral ovarian wedge resection in 47 cases of sterility; 20-
year end results; 75 cases of bilateral polycystic ovaries. Am.
J. Obst. & Gynec. 58:267-274, 1949.

7. McCutchen, G. T., and Kinder, E. C.: Bilateral polycystic

ovaries (large white ovaries). J. South Carolina M. A. 47:1-7,
1951.

8. Katzberg, A. J.: Bilateral polycystic ovaries. J. South Caro-

lina M.A. 48:154-155, 1952.

9. Broady, Harold: Infertility and polycystic ovaries: a case

report. Connecticut M. J. 17:217, 1953.

10. Stern, O. N.: Stein-Leventhal syndrome. Delaware M. J.
28:29, 1956.

11. Davis, Clarence D., Aske, J. R., and Austin, James: Scle-
rotic polycystic ovary syndrome. South. M. J. 49:856, 1956.

12. Brown, C. W., and Bradford, W. Z.: Ovarian resection in
Stein-Leventhal syndrome. North Carolina M. J. 15:213-217,
1954.

13. Dennis, E. J., and Salley, J. A.: Bilateral polycystic ova-

ries; Stein-Leventhal syndrome. J. South Carolina M. A. 53:
181, 1957.

14. Stein, I. F., and Leventhal, M. L.: Amenorrhea associated
with bilateral polycystic ovaries. Am. J. Obst. & Gvnec.
29:181-191, 1935.'

15. Bailey, K. V.: Operation of extroversion of ovaries for func-
tional amenorrhoea especially of secondary type. I. Obst. &
Gynec. Brit. Emp. 44:637-649, 1937.

16. Ingersoll, F. M., and McDermott, W. V., Jr.: Bilateral

polvcystic ovaries, Stein-Leventhal syndrome. Am. J. Obst. &
Gynec. 60:117-125, 1950.

17. Dockerty, M. B., Lovelady, S. F., and Foust, C. T.: Car-
cinoma of corpus uteri in young women. Am. 1. Obst. &
Gynec. 61:966, 1951.

18. Jackson, Richard L., and Dockerty, M. B.: Stein-Leven-

thal syndrome: analysis of 43 cases with special reference to
association with endometrial carcinoma. Am. J. Obst. &
Gynec. 73:161, 1957.

19. Meaker, S. R.: Ovarian resection for relief of sterility. Fer-

til. & Steril. 1:293-305, 1950.

20. Sommers, S. C., and Wademan, P. J.: Pathogenesis of poly-
cystic ovaries. Am. J. Obst. & Gynec. 72:160, 1956.

21. DuToit, I). A. H.: Polycystic Ovaries, Menstrual Disturb-

ances and Hirsutism. Perblicker, Stenfert, Kroese: Levden,
Holland, 1951.

22. Vara, P., and Niemineva, K.: Stein-Leventhal syndrome.

Ann. chir. et gynaec. Fenniae 40:23-33, 1951.

23. Reynolds, S. R. M.: Distortion of spinal artery in ovary as-
sociated with corpus hemorrhagecum cysts. Endocrinology 40:
388-394, 1947.

24. Delson, B.: Nonneoplastic ovarian cysts; their relation to

spinal arteries in human ovary. Am. J. Obst. & Gvnec. 57:
1120-1132, 1949.

25. Speert, Harold: Carcinoma of endometrium in young wom-
en. Surg. Gynec. & Obst. 88:332-336, 1949.

26. Reycraft, J. L.: Operative procedures for treatment of

sterility and ovarian dysfunctions. Am. 1. Obst. & Gynec. 57:
1069-1076, 1949.

27. Sommers, S. C., Hertig, A. T., and Bengloff, Harold:
Genesis of endometrial carcinoma. II: cases 19 to 35 years
old. Cancer 2:957, 1949.

28. Van Wagenen, G., and Morse, A. H.: Uterine and ovarian
response to partial and subtotal ovarian resection. Endo-
crinology 30:459-464, 1942.

29. Novak, Emil: Discussion of Reycraft, James L.: Operative
procedures for treatment of sterility and ovarian dysfunctions.
Am. J. Obst. & Gynec. 57:1069-1076, 1949.

30. Hirsch, E. F.: Discussion of Stein, I. F.: Bilateral poly-

cystic ovaries; significance in sterility. Am. J. Obst. & Gvnec.
50:385-398, 1945.

31. Jacobsen, P.: Preservation of function in cystic and sclerotic
ovaries; report of 16 cases of single ovarv. Surg. Gvnec. &
Obst. 87:31-43, 1948.

32. Dockerty, M. B., and Mussey, E.: Malignant lesions of

uterus associated with estrogen-producing ovarian tumors.
Am. J. Obst. & Gynec. 61:147-153, 1951.

33. Dockerty, M. B., and MacCarty, W. C.: Granulosa cell tu-
mors with report of 34-lb. specimen and review. Am. J. Obst.
& Gynec. 37:425, 1939.

34. Speert, Harold: Endometrial cancer and hepatic cirrhosis.

Cancer 2:597-603, 1949.

35. Greene, H. S. N.: Uterine adenomata in rabbit: susceptibility
as function of constitutional factors. T. Exper. Med. 73:273,
1941.

36. Banner, E. A., and Dockerty, M. B.: Theca cell tumors of
ovary; clinical and pathologic study of 23 cases ( including
13 new cases) with review. Surg. Gynec. & Obst. 81:234-
242, 1945.

37. Herrell, W. E.: Studies on endometrium in association with
normal menstrual cycle with ovarian dysfunctions and cancer
of the uterus. Am. J. Obst. & Gynec. 37:559, 1939.

38. Greenblatt, R. B.: Cortisone in treatment of hirsute woman.
Am. J. Obst. & Gynec. 66:700-710, 1953.

39. DeVere, R. D., and Dempster, K. R.: Case of Stein-Leven-
thal syndrome associated with carcinoma of endometrium.
J. Obst. & Gynec. Brit. Emp. 60:865-867, 1953.

420

THE JOURNAL-LANCET

Maternal Mortality in North Dakota

JOHN H. MOORE, M.D.

Grand Forks, North Dakota

The north Dakota state medical associa-
tion and the North Dakota Society of Ob-
stetrics and Gynecology, in cooperation witli the
North Dakota State Department of Health, con-
tinue to sponsor a research project in maternal
mortality. It is a combined effort to reduce still
further the already low maternal death rate and
to improve the quality and standards of obstetric
care throughout the state. The passage of House
bill No. 599 by the thirty-fifth legislative assem-
bly of North Dakota authorized research studies
conducted by the State Department of Health
and other agencies “for the purpose of reducing
the morbidity or mortality from any cause or
condition of health" and provided that such in-
formation “shall be confidential and shall be used
solely for the purpose of medical or scientific re-
search.” These studies have been conducted in
strict conformity with the law, and I am sure
that I express the feeling of the Review Board,
the several consultants who have conducted the
individual surveys, the North Dakota State
Department of Health, as well as my own feel-
ings as coordinator of the program and con-
sultant in obstetrics to the State Department of
Health that they are proving most valuable as a
research study into causes of maternal deaths.

The Maternal Mortality Review Board consists
of practicing physicians in North Dakota ap-
pointed by the several district medical societies
of the North Dakota State Medical Association,
thus giving state- wide representation. The co-
ordinator assigns the consultants for the various
maternal death studies, receives and tabulates
their reports, acts ex officio as chairman of the
Review Board and presents each individual case
to the Review Board with strict anonymity main-
tained as to name of patient, name of attending
physician or physicians, and place of death.

Photostatic copies of death certificates are sent
to me by Margaret Watts, director of the Bureau
of Vital Statistics, as soon as she discovers a

john h. moore is with the Department of Obstetrics
and Gynecology at the Grand Forks Clinic.

Paper presented at the annual meeting of the
North Dakota State Medical Association in Minot ,
May 1958.

death certificate for a maternal death or if preg-
nancy has been mentioned as having occurred
six months before death. Such prompt reports, of
course, furnish the bulk of our research material;
but, in addition, reports are sometimes received
from physicians and from hospitals where preg-
nancy had not been mentioned on the death
certificates, not with any attempt to conceal the
fact but simply because the reporter did not
think such information was pertinent at the time
the death certificate was signed. When such
cases are reported to me, I request copies of the
death certificates from the State Department of
Health and refer them to consultants for study.

In our studies, we furnish each consultant with
an 18-page questionnaire, designed by the Min-
nesota Maternal Mortality Study Committee and
modified to suit our particular needs, and we
gratefully acknowledge this courtesy from our
Minnesota colleagues. By using such a question-
naire, we obtain a pertinent uniformity in the
surveys even though they are conducted by vari-
ous consultants, so that abstracting them for
presentation to the Review Board is greatlv fa-
cilitated. The physicians and the hospitals of
North Dakota have even put themselves to con-
siderable inconvenience at times to give our
consultants the desired information so that when
they are returned to me for abstracting, they
often contain additional source material of much
scientific value to the study.

The Review Board has classified North Dakota
hospitals as follows: small rural hospitals, 30
beds or under; medium rural hospitals, 30 to 50
beds; metropolitan hospitals, 50 beds or more.

The classification adopted by the Review
Board is simple and adequate in form but not so
simple, though still adequate, in application. By
individual vote of each member of the Board in
attendance, the following questions are answered
after each case has been individually presented
and discussed: Was this an obstetric or a non-
obstetric death? Was it preventable or nonpre-
ventable? If it was preventable, was it the re-
sponsibility of (a) patient, (b) physician, (c)
hospital or other responsibility, or (d) was it
impossible to fix the responsibility?

The first meeting of the Review Board was

OCTOBER 1958

921

held on April 27, 1956, when 11 deaths were re-
ported. Seven of them occurred in metropolitan
hospitals and 4 in medium rural hospitals.

Six cases included hemorrhage as either an
immediate or an associated cause of death. These
included 2 cases of postpartum hemorrhage, 1
from incomplete abortion, 2 said to have been
associated with abruptio placentae, and 1 from
a rupture of the uterus.

Two deaths were attributed to pulmonary
embolus.

Four deaths were due to diseases complicating
pregnancy. One was from acute infectious en-
cephalitis, which was verified at autopsy; 1 was
from acute hepatitis, with autopsy showing acute
yellow atrophy of the liver secondary to the
acute hepatitis; another was due to leukemia
four months after the birth of her second child;
and the fourth occurred at eighteen weeks’ ges-
tation from syringomyelia and bronchopneu-
monia, which were confirmed by autopsy and
reported after the Review Board had met.

In summarizing the deaths of the 12 patients
in this first series, hemorrhage was directly or
indirectly etiologic in 50 per cent, embolism in
16.6 per cent, and disease in 33.4 per cent.

Of the 10 patients whose deaths were regarded
as not preventable, 1 patient may represent
patient and/or family responsibility and a second
case, patient responsibility. There were 2 pa-
tients remaining in the series of 12 whose deaths
the Review Board believed were the physician’s
responsibility. There were no primiparous pa-
tients in this first group. Gravidity ranged from
2 to 7 and ages from 27 to 42.

Since the Review Board had decided at its first
meeting that it was not practical to hold regular
meetings but that it would meet when the num-
ber of cases prepared by the coordinator war-
ranted such a meeting, the next meeting was
held on November 2, 1957. At that time, I pre-
sented 7 cases for the Board’s consideration.
Gravidity ranged from 1 to 15 with but 1 primi-
parous patient in the group. The majority of the
Board decided that 4 of these deaths were pre-
ventable and that 3 were not preventable.

Before presenting the 1957 report of the Re-
view Board, I present 2 charts, prepared through
the courtesy of the Division of Vital Statistics of
the North Dakota State Department of Health
by Margaret Watts, director, and having a bear-
ing on this problem of maternal mortality. These
are the place of occurrence rates (table 1) and
the residence rates, ( table 2 ) and both are self-
explanatory. It will be noted that maternal death
rates, in both charts, are based on 10,000 live
births. I have no immediate explanation for the

TABLE 1

PLACE OF OCCURRENCE RATES
NUMBER OF LIVE BIRTHS AND MATERNAL DEATHS
WHICH OCCURRED IN NORTH DAKOTA REGARDLESS OF
RESIDENCE OF MOTHER

Year

No. of
live births

No. of

maternal deaths

Maternal death
rate per 10,000
live births

1950

17,183

9

5.2

1951

17,136

13

7.6

1952

17,158

7

4.1

1953

16,987

9

5.3

1954

17,472

6

3.4

1955

17,347

6

3.5

1956

16,833

2

1.2

Division of Vital Statistics, State Department of Health,
December 12, 1957.

TABLE 2

RESIDENCE RATES

NUMBER OF LIVE BIRTHS AND MATERNAL DEATHS
OCCURRING TO RESIDENTS OF NORTH DAKOTA
AND MATERNAL DEATH RATE PER 10,000 POPULATION

Year

No. of
live births

No. of

maternal deaths

Maternal death
rate per 10,000
live births

1950

17,076

9

5.3

1951

17,288

11

6.4

1952

17,356

6

3.5

1953

16,944

11

6.5

1954

17,432

6

3.4

1955

17,239

6

3.5

1956

16,626

2

1.2

Division of Vital Statistics, State Department of Health,
December 12, 1957.

rise in 1951 and in 1953, but it is interesting to
note the figures for the seven-year period, 1950
to 1956, inclusive, and to attempt to lower even
the 1.2 figure for 1956. In 1935, when the North
Dakota Committee on Maternal and Child Wel-
fare was first formed and of which I had the
honor to be chairman for ten years, the maternal
mortality rate was 55 per 10,000 live births. In
1940, it had dropped to 17 per 10,000 live births,
but, in 1943, it had risen to 29 per 10,000 live
births, and it is interesting to note that in this
year, obstetric hemorrhage went into first place
as a cause of maternal deaths, ahead of infection
and toxemia. An analysis of the individual case
summaries of maternal deaths from hemorrhage
during that year showed that 2 factors were
chiefly responsible for the rise: (1) injudicious
operative obstetrics and (2) inadequate blood
or blood substitutes. The rate for 1945 was 11
per 1(),()()() live births.

Of the 7 patients in the 1957 series, 2. or 28-
plus per cent, died from hemorrhage; 1 was

422

THE JOURNAL-LANCET

listed by the Review Board as nonpreventable
and 1 as preventable.

Two patients died from rheumatic heart dis-
ease and 1 from multiple sclerosis, or 42-plus
per cent. In 1 of the rheumatic heart disease
cases, the Review Board felt that death might
have been preventable and that it was due to
patient neglect. The other death from rheu-
matic heart disease was classified as not prevent-
able. The death from multiple sclerosis was clas-
sified as nonpreventable and nonobstetrie.

Of the remaining 2 deaths, or 28-plus per cent,
1 from gangrene of the cecum with perforation
was regarded bv a majority of the Review Board
as preventable and nonobstetrie. The other
from septic abortion was regarded nonprevent-
able by a majority of the Review Board, but the
minority thought it was a preventable obstetric
death with patient responsibility.

Autopsies were obtained in 4 of the 7 deaths,
or in 57-plus per cent.

Five of the deaths occurred in metropolitan
hospitals, but, in 3 of these, the patients were
brought in for terminal care. One death occurred
at a home to which the physician was called and
where he pronounced the patient dead. In this
case, history revealed carditis of twenty years’
duration with mitral valve involvement, and,
since there were no hospital records and prepar-
tum care had not been given, it was felt by the
majority of the Review Roard that an autopsy
should have been done.

Life and death, those mysteries which remain
such challenges to humanity and which we, as
physicians, must try to interpret intelligently to
our patients, leave us with a sense of great hu-
mility. In the presence of a maternal death, we
are especially concerned because the patient
died while trying to bring life and because the
remarkable reduction of maternal deaths during
the past quarter of a century in North Dakota,
from 55 per 10,000 live births in 1935 to 1.2 per
10,000 live births in 1956, has made us even more
critical in our analysis of any maternal death
which does occur.

I have had members of the Review Board tell
me that they regard service on that Board as
most valuable postgraduate training in obstetrics,
and the consultants have spoken similarly. I sup-
pose that all of us have, at times, become an-
noyed at what seems unnecessary “paper work”
in keeping office and hospital records; but let me
present some comments of the Review Board on
the most recent series of maternal deaths.

“Improper death certificate; no consultation,
no laboratory work-up with facilities available,
no progress reports written on chart, lack of in-

formation, error of omission. Hospital error: Lack
of administrative medical control and poor re-
cord keeping."

Again, “Poor recording of nurses. No past
history or prenatal record. No postpartum rec-
ord. No laboratory work-up. Adequate space
not provided for records.

In another instance, it was noted, “History and
physical examination sketchy. No family history.
No physician progress notes. No nurses’ notes.
No reference to vital signs. No blood pressure
determination. Time elements very inaccurate.
No notation as to time and amount of medica-
tion. No written consultation notes. No consul-
tation suggestions on chart. No anesthetic rec-
ord. No operative notes. No attention to left
lower quadrant pain or to impending and current
shock. No notation of postpartum procedures.
No medical staff review of records. No note of
autopsy on the chart.

It is not the contention of the Review Board
or of the writer that perfect records would have
saved the lives of these 3 women, but it is the
feeling of the Review Board that obstetric prac-
tice in North Dakota would benefit greatly if a
uniform system for keeping obstetric records
could be introduced into our hospitals which, at
present, do not have such systems. Reports should
include information pertinent to the pregnancy
and labor, and newborn records and a laboratory
record should be kept. Also, progress notes,
particularly in pathologic cases and those in
which consultation is employed, should be ac-
curately kept. Adequate review of the records
by the staff and sufficient storage space to keep
them is felt to be of great importance.

CONCLUSIONS

Obstetric hemorrhage continues to be a major
cause of maternal deaths in North Dakota. We
are very fortunate in having our state blood
bank, plasma bank, and walking blood banks
so widely distributed in North Dakota.

Certain medical diseases have caused a num-
ber of maternal deaths as listed in these 2 sur-
veys, and no known cures are yet available for
most of these. Nevertheless, these are important
contributory factors in maternal deaths and em-
phasize the necessity for frequent consultations
and adequate records in the hope that the dis-
ease may be arrested before a fatality occurs.

We have reached our enviable, low maternal
mortality by patient and persistent efforts in the
education of ourselves, our patients, and the
public at large. Let us continue those efforts,
for, in that way, lies still greater hope for the
pregnant woman and her baby.

OCTOBER 1958

423

The Postoperative Chest, by Hiram
T. Langston, M.D., Anton M.
Pantone, M.D., and Myron
Melamed, M.D., 1958. Spring-
field, Illinois: Charles C Thomas,
228 pages. $8.00.

This is the second publication in the
John Alexander monograph series on
various phases of thoracic surgery.
The format is of atlas style, present-
ing reproductions of roentgenograms
with illustrative sketches selected
from over 300 cases from the Chi-
cago State Tuberculosis Sanitarium.

There are many roentgenographic
changes seen in the postoperative
chest pertaining to the incision,
drainage tubes, ribs, diaphragm, me-
diastinum, pleura, and lungs which
might be called “expected” changes,
considering the surgery performed.
Complications, such as excess air in
soft tissues, pneumothorax, chronic
pneumothorax, mediastinal emphy-
sema, bleeding into soft tissues or
pleural cavity, mediastinal displace-
ment, infections, bronchopleural fis-
tula, atelectasis, and pneumonia are
illustrated.

The use of high kilovoltage tech-
nic is encouraged. Bronchography
and laminography are freely used
preoperatively and in the postopera-
tive state in defining more precisely
the extent and relationships of vari-
ous lesions.

REVIEWS

The correlation of type of surgical
procedure, clinical condition of the
patient, and time factors are utilized
in evaluating the importance of the
various roentgenologic findings that
are encountered in the postoperative
state.

Charles M. Nice, Jr., M.D.

The Conquest of Bovine Tubercu-
losis in the United States, by
Howard R. Smith, Somerset,
Michigan. Order direct from the
author. $1.00.

This volume of less than 100 pages
is an account of the most pheno-
menal accomplishment in tubercu-
losis control that has ever been
achieved among animals or people
in a major nation.

Table 3 of this book shows the
effectiveness of this program. In
1917, of the 9,276,049 market cattle
slaughtered, the carcasses of 8,418
had to be sterilized as unfit for food,
and 40,756 were condemned be-
cause of tuberculosis: whereas in
1957, of the 20,141,371 market
cattle slaughtered, the carcasses of
only 16 had to be sterilized and
only 196 condemned. This is a 99.7
per cent decrease in proportion to
the number slaughtered. Among the
95,000,000 cattle in the United
States during the fiscal year 1957,
testing with tuberculin revealed that
only 0.156 per cent were harboring
tubercle bacilli.

In a most fascinating way, H. R.
Smith, Doctor of Agriculture, tells
how this accomplishment was a-
chieved. In 1912, as head of the
Department of Animal Husbandry at
the University of Nebraska, Smith
transferred to the chairmanship of
the Department of Animal Hus-
bandry at the University of Minne-
sota. In 1915, he became livestock
specialist for the organizations which
James |. Hill, St. Paul, represented,
including the Great Northern Rail-
road and the First National Bank of
St. Paul. In 1917, he became live-
stock commissioner for the market
interests in Chicago in order to de-
vote his entire time to educational
( Continued on page 454 )

(CONCLUSION)

Transactions of the North Dakota
State Medical Association

Seventy-First Annual Meeting
Minot, North Dakota, May 3, 4, 5, and 6, 1958

Report of the Reference Committee on Resolutions
and New Business

Dr. T. E. Pederson, chairman of the committee, pre-
sented the following resolutions:

RESOLUTION

Whereas, the members of the North Dakota State Medical
Association attending the seventy-first annual meeting of the asso-
ciation in Minot having enjoyed the hospitality and kindness of
this fair city, and

Whereas, the mayor of Minot and his associates, the press, and
radio, the hotels, and business men have made this session one
long to be remembered.

Now, therefore, he it resolved that the House of Delegates ex-
press their appreciation by directing a copy of this resolution to
the Honorable Mayor of Minot.

This resolution was adopted.

RESOLUTION

Whereas , the Woman’s Auxiliary to the North Dakota State
Medical Association has, through various projects entailing con-
tinuous work and effort, raised the sum of approximately $14,000
for their Medical Student Loan Fund at the medical school of the
University of North Dakota, and

Whereas , this fund has been of great value to many medical
students and to the medical school, and

Whereas, other worthwhile projects, such as mental health and
nurse recruiting; fostering Today’s Health magazine; social legis-
lative endeavors, especially those directed against the Forand hill;
initiation of essay contests; and sponsorship of the Medical Stu-
dent Wives’ Association, all made for continuing good will for the
medical profession in North Dakota,

Now, therefore, he it resolved that the House of Delegates of
the North Dakota State Association convey to the Woman’s Auxil-
iary of the association their appreciation and thanks for their ex-
cellent work and vision in their splendid projects, and

424

THE JOURNAL-LANCET

Be it further resolved that a copy of this resolution be directed
to the president of the Woman’s Auxiliary.

This resolution was adopted.

RESOLUTION

Whereas, the exhibitors have shown great effort and interest in
this meeting and former meetings in developing their exhibits and
adding to the scientific interest,

Note, therefore, he it resolved that the North Dakota State
Medical Association extend to them our hearty welcome and
thanks, and

Be it further resolved that a copy of this resolution be sent to
each exhibitor.

This resolution was adopted.

RESOLUTION

Whereas, Dr. Leonard Larson, a trustee of the A.M.A.; Dr.
Willard Wright, our delegate to the A.M.A. and chairman of the
Medical and Related Facilities Committee of the A.M.A. ; and Dr.
C. J. Glaspel, secretary of the North Dakota State Board of Med-
ical Examiners and past-president of the Federation of Medical
State Boards have done yeoman service and brought honor to the
North Dakota State Medical Association,

Now, therefore, he it resolved that this association take cog-
nizance of their services and pay tribute to these men for their
efforts on behalf of the North Dakota State Medical Association,
and

Be it further resolved that a copy of this resolution be forward-
ed to each of these men.

This resolution was adopted by the members of the
House of Delegates and given a round of applause.

RESOLUTION

Whereas, Dr. R. W. Rodgers, president of the North Dakota
State Medical Association for the year 1957 and 1958 has given
untiringly and unselfishly of his time and services toward the
continued progress of medical practice in North Dakota,

Now, therefore, be it resolved that the assembled delegates
show their appreciation by a rising vote of thanks.

A rising vote of thanks adopted this resolution.

RESOLUTION

Whereas, the A.M.A. interim meeting will be held in Minne-
apolis in December 1958, and

Whereas, the scientific session of this meeting is of such high
caliber as to benefit the members of the North Dakota State Med-
ical Association, and

Whereas, by our enthusiastic attendance at this meeting, great
benefits could befall our profession in North Dakota,

Now, therefore, be it resolved that our executive secretary be
directed to duly publicize this meeting to the end that members
of our state association might attend this meeting in dedicated
numbers.

This resolution was adopted.

RESOLUTION

Your resolutions committee considered at length the resolution
presented by Dr. Edmund Vinje at the first session of the House
of Delegates, directing the legislative research committee to spon-
sor legislation in the 1959 session of the North Dakota legislature
designed to obtain a doctor of medicine as state health officer at a
stated salary of $12,500 per year. Your resolutions committee
concurs with the intent of this resolution; namely, the early em-
ployment of a qualified medical doctor as state health officer.
But, because of the incorporation of salary limitation in the origi-
nal resolution, your committee rejects said resolution and offers the
following substitute resolution:

Whereas, North Dakota is the only state in the United States
which does not have a doctor of medicine as state health officer,
and

Whereas, the need for a qualified doctor of medicine as state
health officer is necessary for the health welfare of our state,

Now , therefore, be it resolved that the House of Delegates of
the North Dakota State Medical Association direct the state health
council to obtain a qualified doctor of medicine as state health
officer at the earliest possible date.

Dr. Pederson moved the adoption of this substitute
resolution. Motion was seconded bv Dr. Vinje and
adopted.

RESOLUTION

Your reference committee has considered the resolution pre-
sented by Dr. Lund, chairman of the Committee on Cancer, at
the first session of the House of Delegates referring to the estab-
lishment of a central cancer registry, and vour reference committee
wishes to delete the last paragraph of said resolution which reads:
“Be it resolved that the North Dakota State Medical Association
recommend the establishment of a central cancer registry to be
established and maintained at no expense to the North Dakota

Medical Association and be located and maintained by the Bureau
of Vital Statistics of the United States Public Health Service in
Bismarck.”

Your reference committee offers the following resolution as a
substitution for the deleted paragraph:

Now, therefore, he it resolved that the House of Delegates of
the North Dakota State Medical Association recommend the early
establishment of a central cancer registry, and

Be it further resolved that this project be referred back to the
Committee on Cancer for further study and report to the council
at its interim session.

Dr. Pederson moved the adoption of this resolution as
amended. Dr. Nugent seconded and the resolution was
adopted.

RESOLUTION

Your resolutions committee considered the resolution presented
at the first session of the House of Delegates by the delegates
from the First District Medical Society, referring to accredited
attendance at State Medical Association deliberations by lay “ob-
servers.” Your committee wishes to amend this resolution with
the following stipulation in the first sentence of the last paragraph,
to read: “If the sponsoring district society approval is accom-
plished by a majority vote of the membership, the Credentials
Committee shall be authorized to accept these individuals as “ob-
servers.”

This resolution, with the amendment, was adopted.

RESOLUTION

The following resolution of the North Dakota Physicians Service
Board of Directors was presented to your resolutions committee as
a belated resolution.

Whereas, North Dakota Physicians Service is legally organized
by doctors of medicine to provide a prepayment plan for eligible
North Dakota residents who by reason of illness or accident re-
quire the professional services of a doctor of medicine; and

Whereas, North Dakota Physicians Service can by law and phy-
sician contracts pay doctors of medicine for professional services
only where such services are rendered or supervised by a doctor
of medicine who customarily bills patients for his services; and

Whereas, North Dakota Physicians Service subscribers who
utilize the facilities of the outpatient department of a hospital for
pathology, radiology, and radiotherapy services receive no benefits
from Blue Shield when any of these before mentioned professional
services are billed as hospital services by the hospital to the pa-
tient;

Now, therefore, be it resolved that the North Dakota Physicians
Service Board of Directors respectfully requests that the council
of the North Dakota State Medical Association be made aware of
this situation and take such action as it deems necessary with the
North Dakota Hospital Association to arrive at an agreement as
to whether these before mentioned services shoidd properly be
considered professional services or hospital services and, if pro-
fessional services, the cost of such to be paid by Blue Shield and,
if hospital services, the cost of such to be the proper responsibility
of Blue Cross.

Your reference committee recommends that this resolution be
referred to the Committee on Medical Economics for considera-
tion and report to the council at its interim meeting.

This portion of the report was adopted.

RESOLUTION

Whereas, the seventy-first annual meeting of the North Dakota
State Medical Association has thoroughly enjoyed and profited by
the scientific program, and

Whereas, the host, the Fourth District Medical Society and the
various chairmen and committeemen have excelled in providing
the membership of the association with the niceties of a gracious
convention.

Now, therefore, he it resolved that assembled delegates demon-
strate their appreciation by a rising vote of thanks.

A rising vote of thanks adopted this resolution.

Dr. Pederson moved the adoption of the report as a
whole. Dr. Van der Linde seconded the motion, and the
report as a whole was adopted.

T. E. Pederson, M.D., Chairman
F. A. DeCesare, M.D.

R. W. Henderson, M.D.

F. D. Naegeli, M.D.

Robert Painter, M.D.

NEW BUSINESS

The Chair next entertained a motion for fixing the per
capita dues for the ensuing year.

Dr. Mahowald moved and Dr. Mahoney seconded that
the dues remain the same. Motion was passed.

OCTOBER 1958

425

The next order of business was the report of Dr. C.
J. Glaspel, secretary of the State Board of Medical Ex-
aminers.

The Chair at this time entertained an invitation for
the location of the 1959 meeting. Through a conflict with
the dates for the 1959 meeting of the North Dakota State
Dental Association, the meeting normally scheduled for
Grand Forks cannot be held.

Dr. Carl Baumgartner, representing the Sixth District
Medical Society, extended an invitation to the House of
Delegates to meet in Bismarck in 1959, and he moved
that this invitation be accepted. Motion was seconded
by Dr. Nugent and carried.

The Chair stated that it was felt that the selection of
a meeting place for our regularly scheduled annual meet-
ings should be made at least two years in advance to
eliminate such a conflict as has arisen in 1959.

Dr. Mahowald, representing the Grand Forks District
Medical Society, extended an invitation to the North
Dakota State Medical Association to meet in Grand Forks
in I960. He moved that the invitation be accepted and
Dr. Fischer seconded the motion. Motion was carried.

Report of the Nominating Committee

Dr. E. T. Keller, chairman, gave the following report
of his committee:

President Dr. O. A. Sedlak, Fargo

President-elect Dr. [. C. Fawcett, Devils Lake

First vice-president Dr. C. M. Lund, Williston

Second vice-president Dr. E. H. Boerth, Bismarck

Speaker of the House Dr. G. A. Dodds, Fargo

Vice-speaker of the House Dr. B. E. Leigh, Grand Forks
Secretary Dr. R. D. Nierling, Jamestown

Treasurer Dr. E. |. Larson, Jamestown

Delegate to the A.M.A. Dr. VV. A. Wright, Williston
Alternate delegate to the A.M.A.

Dr. T. E. Pederson, Jamestown
Councillors (Terms expiring in 1961):

Second District Dr. G. W. Toomey, Devils Lake

Seventh District Dr. T. E. Pederson, Jamestown

Ninth District Dr. A. R. Gilsdorf, Dickinson

Eighth District Dr. J. D. Craven, Williston

Board of medical examiners (terms expiring in 1961):

Dr. D. J. Halliday, Kenmare; Dr. V. G. Borland,
Fargo; and Dr. C. A. Arneson, Bismarck.

State Health Council:

Dr. R. F. Gilliland, Dickinson

Dr. Johnson moved that the report of the nominating
committee be accepted. Motion was seconded by Dr.
Fawcett and passed. The nominations were accepted
unanimously, and all nominees have been elected.

E. T. Keller, M.D., Chairman

A. K. Johnson, M.D.

F. A. DeCesare, M.D.

Speaker Dodds next addressed the delegates concern-
ing a change in the Constitution as approved at the 1957
session. Authority was given by the House to print the
Constitution with the motion as being adopted, so that
the reprinting include the suggested revisions in the Con-
stitution. This, of course, requires action by this 1958
session. On the assumption that the House would pass
this revision in the Constitution, the Constitution and Bv-
laws were printed. Secretary Boerth was requested to
read this change, which must be adopted or disapproved
at this time.

Article IX, Section 2 reads:

The president, the president-elect, vice-presidents, secretary and
treasurer shall be elected annually by the House of Delegates to
serve for a term of one year. The councillors shall be elected hv
the House of Delegates annually to serve for a term of three

years; limit of consecutive terms shall be two. Instances where
councillors are elected to fill the unexpired terms of previous
councillors, the portion of the unexpired term shall not be includ-
ed in the limit of the two consecutive terms referred to above.
The term of the councillor-at-large shall not be included in the
limit of the two consecutive terms referred to above.

Dr. Gillam moved that the House approve this revision
of the constitution. Motion was seconded by Dr. Ham-
margren and carried. The above revision of the constitu-
tion is approved.

There being no further new business to come before
the House, the Chair at this time thanked the delegates
for their efforts and again reiterated tire advice given by
the president that the delegates select 1 delegate to re-
port to their district society on the transactions of this
annual session.

The motion was made, seconded, and passed for ad-
journment. Meeting adjourned at 5:00 p.m.

SCIENTIFIC PROGRAM

May 5, 1958

Municipal Auditorium, Minot

8:30 to 9:15 a.m. — Registration.

9:15 to 9:30 a.m. — Greetings from mayor of Minot and presi-
dent of the Northwest District Medical Society.

9:30 to 10:00 a.m. — “The Failure of Extensive Partial Gastrec-
tomy with Gastro-Duodenostomy in the Treatment of Duo-
denal Ulcer,” Dr. Norman Ordahl, Dickinson.

10:00 to 10:30 a.m. — “Prevention and Management of Infec-
tions in Fracture Treatment,” Dr. John H. Moe, Minne-
apolis.

10:30 to 11:00 a.m. — Intermission to view exhibits.

11:00 to 11:30 a.m. — “Injuries to the Urinary Tract,” Dr. Her-
bert E. Landes, Ghicago.

11:30 to 12:00 noon — “Thoracic and Abdominal Injuries,” Dr.
G. Alfred Dodds, Fargo.

NOON RECESS

1:30 to 2:00 p.m. — “Some Uncommon Complications of Pyelo-
nephritis,” Dr. Edwin G. Olmstead, Grand Forks.

2:00 to 2:30 p.m. — “Curable Hypertension,” Dr. Ray Gifford,
Jr., Rochester.

2:30 to 3:00 p.m. — “Presymptomatic Diagnosis of Cancer,” Dr.
W. Albert Sullivan, Jr., Minneapolis.

3:00 to 3:30 p.m. — Intermission.

3:30 to 4:00 p.m. — “Male Hypogonadism,” Dr. L. O. Under-
dahl, Rochester.

4:00 to 5:00 p.m. — “Clinicopathological Conference,” Dr. J. D.
Capdy, Grand Forks, moderator; Dr. Ray W. Gifford, Jr.,
Rochester; Dr. L. O. Underdahl, Rochester; and Dr. Lau-
rence G. Pray, Fargo.

6:30 p.m. — Special society dinner meetings.

May 6, 1958

Municipal Auditorium, Minot

8:30 to 9:00 a.m. — Registration.

9:00 to 9:30 a.m. — “Human Infertility: Newer Concepts of
Diagnosis and Treatment,” Dr. John S. Gillam, Fargo.

9:30 to 10:00 a.m. — “Maternal Mortality in North Dakota,” Dr.
John H. Moore, Grand Forks.

10:00 to 10:30 a.m. — “Advances in Hearing Restoration,” Dr.

O. E. Halberg, Rochester.

10:30 to 11:00 a.m. — Intermission, exhibit time.

11:00 to 11:30 a.m. — “Common Cerebrovascular syndrome. Diag-
nosis and Treatment,” Dr. A. B. Baker, Minneapolis.

11:30 to 12:00 noon — “Surgical Diseases of the Large Intestine in
Infancy and Childhood,” Dr. Tague C. Chisholm, Minne-
apolis.

NOON RECESS

1:30 to 2:30 p.m. — “Presidential Address,” Dr. R. W. Rodgers.
president. North Dakota State Medical Association.

2:30 to 3:00 p.m. — “The Treatment of Intractable Pain,” Dr.
Wallace P. Ritchie, St. Paul.

3:00 to 3:30 p.m. — Intermission.

3:30 to 4:00 p.m. — “X-Ray Examination of GI Tract, Demon-
strated by Cine-Fluoroscopy,” Dr. Joseph Jorgens, Minne-
apolis.

4:00 to 5:00 p.m. — Panel Discussion: “Intestinal Obstruction,”
Dr. Norman Ordahl, Dickinson, moderator; Dr. Tague C.
Chisholm, Minneapolis; Dr. Wallace P. Ritchie, St. Paul;
Dr. R. F. Nuessle, Bismarck; and Dr. Joseph Jorgens,
Minneapolis.

426

THE JOURNAL-LANCET

PRESIDENTIAL ADDRESS
R. W. Rodgers. M.D.

It is just thirty years ago today since I arrived from
Canada to begin the practice of medicine in North Da-
kota. This has covered a period of many brilliant ad-
vances in the science of medicine and surgery, with the
extension of life expectancy by over ten years. During
this same time, there have been many far reaching socio-
economic changes, and it is to this aspect that I wish to
direct your attention today.

We live in the last great outpost of free enterprise
capitalism, yet the medical profession is in the paradoxic
position of fighting that which seems to be a losing battle
to save itself — a very significant phase of this system from
going down the road to socialization. While it is a firm
conviction that the majority of the United States citizens
do not truly wish a socialized state, a socialized nation,
or socialized medicine, nevertheless, we have constantly
lost ground during the last two decades. Chipping away
of professional freedom and its acceptance by the people
cannot be easily combated. Socialism is just like preg-
nancy— one cannot have just a little — it grows and grows.
In democracies, the welfare state is the beginning and
the totalitarian state the end. The two submerge into the
third sooner or later.

There are at present 43 million people, or one-fourth
of the population, eligible to receive some medical or
hospital aid from governmental sources, and new legis-
lation may add 7 million more. Should the Forand bill
be passed, adding another 13/2 million to those eligible
for assistance, about one-third of our population would
then be encompassed. Public national health cost in the
United States in 1955 was $3.9 billion, and public costs
have since risen sharply. In Great Britain under social-
ized health insurance, the cost of the scheme amounts to
more than 10 per cent of the national budget. This cost
has risen over 300 per cent in the past nine years, during
which time retail prices rose only 40 per cent. This
surely shows that governmental medical care is not free.
Yet, while the total cost is great, the economic position
of the British doctor is pathetically low compared to ours
under the free enterprise system.

The reasons for this trend toward socialization are
many and varied. Some are obvious, others more subtle
and insidious. The demand by the public is demon-
strated by the increasing number of health bills intro-
duced by each succeeding Congress: 250 health measures
in the eighty-second congress, 407 measures in the
eighty-third Congress, and 571 measures in the eighty-
fourth Congress. Rising hospital costs no doubt have
stimulated the trend. It would be well for us to consider
what part our own profession has played. We should ask
ourselves why it is that organized medicine is so often
made the “whipping boy?” Has the doctor been demoted
from his once proud pinnacle of respect and influence
in the community and, if so, why? We should ascertain
what the true feelings of the public are toward doctors
individually and collectively and, with these and other
pertinent facts at our disposal, employ that most difficult
of all arts — self criticism. It is our privilege to defend
that which is right and our moral responsibility to cor-
rect that which is wrong.

It is an odd state of affairs when the vast majority of
persons think of their own private physician as an hon-
orable, trustworthy individual whose integrity they do
not doubt, who is ever willing to answer promptly their
every beck and call, and into whose hands they are will-
ing to place themselves when their very life depends on
his ability. Yet, they view all other doctors and the asso-

ciation of doctors as an evil tiling engaged solely in ac-
quiring power for themselves, regardless ot the welfare
of the people as a whole.

The medical profession, as no other profession, has the
public confidence in its skill, proficiency, and self-dedi-
cation. But, we cannot sit in our ivory towers and as-
sume that everyone knows we are doing a good job. The
time is long past due when every doctor must appreciate
the importance of the science of public relations.

A generation ago, the humble family physician needed
no knowledge of this art. With his genuine human sym-
pathy and understanding, his close association with the
family in their home surroundings, his intimate knowl-
edge of their hopes and tribulations, he was often coun-
sellor as well as doctor. He was present at the birth of
life, he protected it and ministered to its wants through
its earthly journey, adding to its comfort and happiness
and, at its termination, he brought solace and comfort to
the relatives. He was a true friend and he was held in
reverential awe.

But with the changing type of medical practice and
with more intense specialization, the doctor is rapidly los-
ing this close personal contact with the patient, and with
this appears to have come a changing attitude by the
public. The patient is apt to be shifted from one spe-
cialist to another, depending upon which part of his
anatomy is ailing. His bill for service is made out on
a modern billing machine, and his payments are made
to the grim business manager, who to many appears to
lack the milk of human kindness. Medicine to many ap-
pears to be just another business. No one doubts that
the patient receives good medical service and good med-
ical care. This is good public relations, but this alone is
not enough. We must develop and display a deep per-
sonal concern for the patient and his welfare. The utiliza-
tion of good public relations are as much part of medi-
cine as is the science and art.

Every doctor should deliberately enter into the ex-
periences and assume the responsibilities and the dis-
ciplines that have to do with the art of human relations.
We must live up to our responsibilities. It is necessary
that we have not only a deep and consuming interest in
our profession but also in the problems of the public
and, particularly, the communities in which we live.
We must be good citizens before we can be good doc-
tors.

We must espouse the cause of medicine in our home
communities as well as on a state and national level.
Our relationship with the press must be improved by
courteous consideration of their requests for information
and cooperation in their efforts to inform the public.
Before one obtains understanding, there must be com-
munication, and the public must be given a clear insight
into the problems of our profession, an appreciation of
our aims, the high standards of our ethics, and a frank
knowledge of our performance.

In the conduct of our practices, there are many areas
in which we can improve our public relations. Careful
choice of our receptionists and technical assistants is
most important. The first contact at the time the pa-
tient enters the office often leaves a lasting impression.
Therefore, courtesy, kindness, and understanding is man-
datory. Appointments should be kept as nearly on time
as possible, and we must display reasonable concern for
our patients’ time. They should never be left with the
impression that they are being rushed through, but
time must be allowed to hear the patient’s story. Care-
ful, thorough examinations followed by frank explana-
tion will correct the complaint so often heard, “The doc-
tor never tells me anything!” Explain what can be ex-

OCTOBER 1958

427

pected from the treatment. Give to every patient the
very maximum care within our potentiality.

In the best interest of the patient, we cannot ignore
his economic problems. There is too much reluctance on
the part of physicians to frankly discuss with the patient
or his family the probable cost of treatment, and this
lias been a source of much misunderstanding. Much
better relations will exist if the patient has a full under-
standing of the cost before treatment is initiated, and we
will have to learn to overcome our distaste for this phase
of practice.

One of the criticisms of our profession is that we are
always against but never for anything. Opposition alone
is not enough. We cannot procrastinate and wait until
agitators put us on the defensive by proposing something
we cannot accept. We must not let the politicians write
the bills. We must write them so that when the time
comes we can say, “This is right, this is proper, this is
what is best in the public interest.” This will put them
rather than ourselves on the defensive. We must look
forward and anticipate new problems as they arise and
find the answers for their solution. We cannot become
defeatists but must resolutely go forward with the firm
conviction that we are masters of our fate. We cannot
let the chains of regimentation tighten about us and for-
ever hold us in bondage, preventing us from exercising
our personal responsibility. We must adhere to and ac-
tively support the principles of constitutional government
and protect our precious liberties. Every encroachment
must be combated with every power at our command.
This requires that the apathy of many of our members
be dispelled, that every member become enlightened on
legislative matters, that he discuss the problems with his
patients, and that he provide active leadership and par-
ticipation in all good government organizations.

The physician is the one most concerned witli social-
ization because health care is the first item any govern-
ment tries to socialize by reason of universal appeal to
the masses. If medicine fails, there is nothing else that
cannot be subjugated. Physicians, individually and col-
lectively, will probably determine whether or not medi-
cine is socialized. The attitude of every individual citi-
zen toward his own as well as all other doctors will be
an important determining factor. If we establish fees
beyond the reach of the patient to pay without eco-
nomic hardship or if our fees force voluntary insurance
rates to rise beyond the economic ability of the sub-
scriber, we are by such action fostering the socialization
of our profession.

Arrogance has no place in our profession. We can hold
our own or win out in the great human competition only
if we approach our tasks with humility, recognizing the
very substantial and often surprising talents of others.
We must recognize that we do not enjoy an inherited
superiority and that we merit the respect and approba-
tion of society only if we adhere to the traditions and
ethics handed down to us by our predecessors. We must
continue to foster and maintain congenial relationships
with our fellow practitioners, studiously avoiding all
public criticism and evidences of bickering. It would be
well for us to take to heart this advice given by an
author whose name I have unfortunately lost, “When
you have the goods on a man, just sit down and think
it over before you proclaim his shame to the world.
Frisk yourself over carefully and, if you find nothing in
your life that you are ashamed of and nothing that you
would not like to see in print, go ahead and get yourself
a megaphone.”

Many of our members need a better understanding of
the Blue Shield program. Launched by the medical

profession, it has become the foundation of the volun-
tary prepaid system. Distribution of medical care is a
social problem, and making this care available to all
who are not medically indigent at a cost they can af-
ford to pay is the job of Blue Shield in cooperation with
the medical profession. Judge Ben C. Willis of the cir-
cuit court of Florida said, “I would like to impress upon
you that Blue Shield is yours; it is yours to continue to
grow and continue to serve, or it is yours to destroy,
it will do one or the other, it will not stand still. Blue
Shield must meet changing conditions; it must meet
competition; it must seek to give that service to the
public which the public is demanding and which it will
get one way or the other, either from government or
from commercial companies.”

More than any other single factor, Blue Shield has
prevented the socialization of medicine. Strenuous ef-
forts must be made to make all doctors cognizant of the
philosophy and work of Blue Shield and the importance
of Blue Shield in warding off government medicine.
Fifty per cent of doctors in practice have graduated
since 1939, and this is since Blue Shield was started,
hence the necessity of continued indoctrination of doc-
tors about the philosophy behind Blue Shield. Local
county medical societies should develop informed com-
mittees. Blue Shield preserves the finest we have in our
system of economics. It recognizes the value of free
enterprise; it recognizes the freedom of choice of the
patient and the physician. We must find ways and means
of convincing some of our members that even though
Blue Shield was organized by the physician, it is not
operating solely for the benefit of one specialty group,
let alone one doctor, but that it operates for the benefit
of the subscriber also. Blue Shield is far from perfect,
but if we apply ourselves diligently to the task, any defi-
ciencies can and will be corrected. Blue Shield is faced
with many problems, among which are: (1) more com-
prehensive care for the patient, (2) coverage of those
not at present covered, and (3) the answer which open
panels must give to the closed panel type of practice.

Plans must immediately be started for the extension
of prepayment care of the aged and retired as a con-
structive answer to the proposed legislation, such as the
Forand bill, for the care of this segment of our popula-
tion.

The future of our medical schools is a proper concern
of every physician. We are obligated to train young men
and women who can competently take our places when
our usefulness has passed. The medical schools are in
financial difficulty and governmental aid has been sug-
gested. This thought should be abhorrent to all physi-
cians. Medical schools must remain free, and it is per-
haps trite to repeat the Supreme Court ruling of 1942,
“It is hardly lack of due process for government to regu-
late that which it subsidizes.” We have the method at our
disposal which can, if we will only seriously support it.
materially help to keep these schools free. I am grieved
to report that there is still a large segment of our mem-
bership who have not yet been convinced that it is not
only our privilege but our duty to make an annual dona-
tion to our medical schools. It appears that much educa-
tional work must be done before we can approach our
goal of having every physician participate in this pro-
gram.

A second problem of the medical school is the lack
of sufficient applicants for admittance who are properlv
qualified. This is true in our own North Dakota school.
A recent letter from Dean Harwood states, "We always
scrape the bottom of the barrel. Of 52 applications from
North Dakota students, we could not find 40 who met

428

THE JOURNAL-LANCET

all the requirements and had a 1.5 average. Our com-
mittee on admissions voted to admit 1 doctor’s son from
among 5 who applied ( several were from out of the
state). I think the basis of the problem is that very
likely the average busy doctor does not have time to give
much attention to his youngster’s intellectual develop-
ment. You would be surprised if I showed the records
of these 5 doctors’ sons who have applied.” To me this
letter has strong implication. It indicates a serious flaw
in the quality, if not in the quantity, of our high school
educational system. Let us get social education back in
the homes and scientific education back in the schools.
Let us develop students who have a fundamental knowl-
edge of how to read, write, and spell and to express
themselves adequately. Let us inspire their quest for
knowledge and an appreciation of the value of hard
work as well as the satisfaction of a job well done and
instill a proper appreciation of moral and spiritual values.
Let us as citizens in our communities crusade for better
education.

But, I am more disturbed bv the implication that per-
haps we ourselves are failing in our responsibility to
youth and even our own children. Has materialism af-
fected our faith in the social factors of man? What flaw
is there in the conduct of our lives that we fail to inspire
the bright and serious youth of our acquaintanceship to
enter what appears to us the most rewarding of all pro-
fessions. These questions we must answer.

A revised version of an article from the Continental
Digest has a philosophy which is worthy of our consid-
eration. “What is a patient?” There have been times in
recent years when some patients themselves have won-
dered. In segments ot the professional world, the atti-
tude toward them was indifference to say the least, but
here is reassurance; here is what good professional rea-
soning really comes up with about the matter.

A patient is the most important person in any prac-
tice. A patient is not dependent upon us; we are de-
pendent on him. A patient is not an interruption of our
work; he is the purpose of it. A patient does us a favor
when he comes for an appointment; we are not doing
him a favor by serving him. A patient is part of our
business, not an outsider.

A patient is not a cold statistic; he is a flesh and blood
human being with feelings and emotions like our own.
A patient is not someone to argue and match wits with.

A patient is a person who brings us his needs; it is
our job to fill those needs. A patient is deserving of the
most courteous and attentive treatment we can give him.

A patient is the fellow who makes it possible for us
to earn a living. A patient is the life blood of mine and
every other doctor’s practice.

I wish to express my thanks to the officers and mem-
bers of our association, who have during the past year
given so graciously of their time and efforts to assist me
in the conduct of the affairs of this society. May I again
sav to all the members of the North Dakota State Med-
ical Association that the honor of having been permitted
to serve as your president is deeply appreciated.

Introduction: Honorary Members and
Fifty-Year Club Members

Dr. R. W. Rodgers; I now come to a very pleasant
part of the program, the recognition of the Fifty-year
members. To belong to this group, one must practice
medicine for fifty years. In the future, it will be difficult
to reach this mark, as, at present, a man needs four
years of college, four years of medical school, and two
years in the army. Consequently, he is not young when
he begins the practice of medicine. With this thought in

mind, it was decided that the Fifty-Year Club should be
made up of those who graduated from medicine fifty
years ago.

We have with us today, 2 members whom we would
like to honor. The first is Dr. Howard B. Huntley, of
Kindred, the father-in-law of the Honorable John Davis,
governor of North Dakota. Dr. Huntley has been a mem-
ber of the First District Medical Society since 1924, hav-
ing formerly practiced in Leonard. He was born April
14, 1876, at Bloomville, Ohio, graduated from North-
western University in 1908, and was licensed in North
Dakota in July, 1908. Ordinarily he would be presented
with both a Fifty-Year Club pin and certificate and an
honorary certificate, but, according to the revised Con-
stitution and Bylaws, anyone who graduated from med-
ical school fifty years ago is now considered an honorary
member.

Dr. Huntley, the North Dakota State Medical Asso-
ciation does hereby award yon the Certificate of Distinc-
tion in recognition of your practice of medicine for fifty
years or more. Your untiring ministry to the ill has done
honor to God, your community, your profession, and
yourself. Permit me to have the honor of pinning this
Fifty-Year pin to your lapel.

I would also like to introduce Mrs. Huntley who has
been his helpmate.

We are also honored today to pay tribute to another
member of our association. Dr. L. H. Landry, of Wal-
halla. He was presented with a Fifty-Year Club pin in
1954. Doctor Landry graduated from the LaValle Uni-
versity, Montreal, Quebec, in 1904. He was licensed in
North Dakota in 1908.

Through your proficient and untiring ministry to the
ill. Dr. Landry, you have done honor to God, your com-
munity, your profession, and yourself. In recognition of
your unselfish devotion to your profession, the North
Dakota State Medical Association hereby awards you the
Certificate of Distinction.

I would also like to introduce Mrs. Landry.

It is indeed a pleasure to have you gentlemen and
your wives here today. We have one other member who
is eligible, but unfortunately he was unable to attend
today. His Fifty-Year pin and certificate will be mailed
to him. He is Dr. George H. Spielman, of Mandan, a
member of the Sixth District Medical Society and a
member of the North Dakota State Medical Association
since 1924. He formerly practiced in Garrison and
Flasher. He was a specialist in proctology. Dr. Spielman
was born on July 16, 1881, in Shakopee, Minnesota. He
graduated in 1908 from Loyola University of C hicago,
and was licensed in North Dakota in July of 1909.

These 3 gentlemen are now considered honorary mem-
bers of the North Dakota State Medical Association.

I now have another very pleasant duty to perform —
the introduction of our next president. He has served
medicine well in many ways. Dr. Waldschmidt, will you
escort Dr. Sedlak, of Fargo, to the platform, and I ask
that all of you stand and salute your next president.

INAUGURAL ADDRESS
O. A. Sedlak, M.D.

I want to thank you for the honor bestowed upon me,
and I hope that a year from now I can stand before you
and you will say “well done, good and faithful servant."

There are many problems and difficulties in the educa-
tion of a medical student, but they are not more difficult
than the continuous education of the general practi-
tioner. Over the first, we have some control; over the
other, none. The university and the state board make
sure that the former has a minimum, at least, of profes-

OCTOBER 1958

429

sional knowledge, but who can be certain of the state
of knowledge of the latter in five or ten years from the
date of graduation? The specialist may be trusted to
take care of himself. His existence demands that he
shall be abreast of the times, but the family doctor —
the private in our great army, the essential factor in the
battle — should be carefully nurtured by the schools and
carefully guarded by the public. Humanly speaking,
with him rest the issues of life and death, since upon him
falls the grievous responsibility in those terrible emer-
gencies which bring darkness and despair to so many
households. No class of men needs to call to mind more
often the wise comment of Plato that education is a
lifelong business.

The difficult problem before us relates to the educa-
tion of the practitioner after he has left school. The foun-
dation may not have been laid upon which to erect an
intellectual structure, and too often the man starts with
a total misconception of the prolonged struggle neces-
sary to keep the education he has, to say nothing of
bettering the instruction of the schools. As the practice
of medicine is not a business, and can never be one, the
education of the heart — the moral side of the man —
must keep pace with the education of the head. Our
fellow creatures cannot be dealt with as a man deals in
grain or coal, the human heart by which we live must
control our professional relations.

For better or worse, few occupations are more satis-
fying than the practice of medicine. During college days,
a man may have worked hard, but whether he becomes
successful or a miserable failure depends upon his atti-
tude toward study after leaving school. After all, the kill-
ing vice of a young doctor is intellectual laziness. With-
out specific subjects upon which to work, he acquires the
newspaper or tbe novel habit and fritters away his ener-
gies upon useless literature. Habits of systematic reading
are rare, and five or ten years after he obtains his li-
cense, the young doctor may know less than when he
started.

Here is where the medical society may step in and
prove his salvation. The doctors’ postgraduate education
comes from patients, books and journals, and from so-
cieties, which should be supplemented every three to
five years by a return to a postgraduate school to over-
come an almost inevitable slovenliness in methods of
work.

One of the most important functions of a medical so-
ciety is to lay a foundation for unity and friendship,
which is essential to the dignity and usefulness of the
profession.

Unity and friendship — how we all long for them but
how difficult to attain. Strife instead seems to be the
very life of the practitioner whose warfare is incessant
against disease, ignorance, and prejudice, and, sad to
admit, he too often lets his angry passions rise against
his professional brothers. Most of the quarrels among
doctors are about nonessential, miserable annoyances —
the pin pricks of practice — which would sometimes try
the patience of fob, but the goodfellowship and friendly
intercourse of the medical society should reduce these
to a minimum.

The well conducted medical society should represent
a clearing house in which every physician would receive
his intellectual rating, and in which he could find out
his professional assets and liabilities. It would keep his
mind open and receptive and counteract the tendency to
premature senility, which is apt to overtake a man who
lives in a routine.

Why do doctors remain out of the folds of their local
medical societies or refrain from attending meetings if
they do belong? In part, this may be due to apathy on
the part of the officers and failure to present an attractive
program, but more often the fault is in the man. Per-
haps a doctor feels it a waste of time to join a society,
and so it is if he is in the profession only for the money
he can get from patients without regard to his sacred
obligation to put himself in the best possible position
to do the best that is known for his patients. More fre-
quently, I fear, the “dollar-doctor” is a regular fre-
quenter of the society, knowing full well that in the
long run isolation from the general body of the profes-
sion is suicidal. The man who knows it all and receives
nothing from the society reminds one of that little dried-
up miniature of humanity, the prematurely senile infant
whose tabetic marasmus has added old age to infancy.
Why should he go to the society and hear Dr. Jones
speak on the gastric relations of neurasthenia when he
can absorb it much better in the works of Ewald? He
is weary of seeing appendices, and there are no new
pelvic viscera for demonstration. It is a waste of time,
lie says, and he feels better at home, and perhaps that
is the best place for a man who has reached this stage
of intellectual stagnation.

Greater sympathy must be felt for the man who
started out all right and worked hard in the societies,
but, as the rolling years have brought ever increasing
demands on his time, the evening hours find him worn
out and yet not able to rest, much less to snatch a little
diversion or instruction in the company of his fellows
whom he loves so well. Of all the men in the profession,
the 40-visit-a-day man is the most to be pitied. Not
always an automaton, lie may sometimes by economy of
words and extraordinary energy do his work well, but
too often he is the one above all others who needs the
refreshment of mind and recreation that is to be had in
a well conducted society. Many good men are ruined by
success in practice and need to pray the prayer of the
Litany against the evils of prosperity. It is only too true,
as you know well, that a most successful — as the term
goes — doctor may practice with a clinical slovenliness
that makes it impossible for that kind old friend. Dame
Nature, to cover his mistakes. A well conducted society
may be of the greatest help in stimulating the practi-
tioner to keep up habits of scientific study.

These words have been taken almost verbatim from
a speech given by Sir William Osier some fifty-five years
ago. The words he uttered then could just as well have
been original thoughts of mine today. New problems
have been added throughout the years, but the basic
principles of the society remain the same.

Years ago some Sister slipped this little card into my
pocket. It is entitled “A Physician’s Prayer”:

Dear Lord , Thou Great Physician , I kneel before Thee.

Since cvertf good and perfect gift must come from Thee , I pray:

Give skill to my haiid, clear vision to my mind,
kindness and sympathy to my heart.

Give singleness of purpose, strength to lift at least a part of
the burden of my suffering fellowmen and a true realization
of the privilege that is mine.

Take from my heart all guile and worldliness that with the
simplest faith of a child I may rely on Thee.

Amen

Many a time when the going was rough, I read this
prayer and it always gave me new strength and courage
to carry on. With this prayer on my lips, I accept the
office of president of the North Dakota State Medical
Association.

430

THE JOURNAL-LANCET

North Dakota State Medical Association Roster — 1958

MEMBERSHIP BY DISTRICTS

FIRST DISTRICT

Amidon, Blaine E. Dakota Clinic, Fargo

Armstrong, William B. Dakota Clinic, Fargo

Bacheller, Stephen C. Enderlin

Bakke, Hans Lisbon

Barnard, Donald M. Fargo Clinic, Fargo

Bateman, Clarence V. 310 Dakota Ave., Wahpeton

Beithon, Elmer |. Red River Valley Clinic, Wahpeton
Beithon, Paul J. Red River Valley Clinic, Wahpeton
Beltz, Melvin E. Wahpeton Clinic, Wahpeton

Borland, Verl G Fargo Clinic, Fargo

Burt, Arthur C. 405 Black Bldg., Fargo

Ghristoferson, Lee A. 702 1st Ave. S., Fargo

Christu, Chris Nl. Fargo Clinic, Fargo

Corbus, Budd C. 314 Black Bldg., Fargo

Crim, Eleanor M. B. 1701 13th St. S., Fargo

Darner, Charles B. Fargo Clinic, Fargo

Darrow, Kent E. Dakota Clinic, Fargo

DeCesare, Francis A. Dakota Clinic, Fargo

Dillard, James R. 311 Black Bldg., Fargo

Dodds, G. A. Fargo Clinic, Fargo

Donat, T. L. Dakota Clinic, Fargo

Engstrom, Perry H. Red River Valley Clinic, Wahpeton
Fercho, Calvin K. 812 Black Bldg., Fargo

Fortney, Arthur C. Fargo Clinic, Fargo

Foster, George C. 15 Broadway, Fargo

Gaebe, Robert C. Casselton

Geib, Marvin J. 702 1st Ave., S., Fargo

Gillam, John S. Fargo Clinic, Fargo

Goff, John R. 304 1st Natl. Bank Bldg., Fargo

Goltz, Neill F. Fargo Clinic, Fargo

Gronvold, Frederick O. 910 Broadway, Fargo

Gustafson, Maynard B. 702 1st Ave. S., Fargo

Hall, G. Howard Fargo Clinic, Fargo

Haugrud, Earl M. 304 Black Bldg., Fargo

Hawn, Hugh W. Fargo Clinic, Fargo

Heilman, Charles O. Fargo Clinic, Fargo

Houghton, James F. Dakota Clinic, Fargo

Hunter, C. M. 608 Black Bldg., Fargo

Hunter, G. Wilson Fargo Clinic, Fargo

Huntley, H. B. Kindred

Irvine, Vincent S. Lidgerwood

Ivers, George U. 424 deLendrecie Bldg., Fargo

Jaehning, David G. Red River Valley Clinic, Wahpeton

Johnsrude, Irwin Fairmount

Klein, Allan L. 410-412 Gate City Bldg., Fargo

Kolner, Edward Enderlin

Kulland, Roy E. 136 1st St. S., West Fargo

Lancaster, YV. E. G. Fargo Clinic, Fargo

Landa, Marshall Dakota Clinic, Fargo

Larson, G. Arthur 812 Black Bldg., Fargo

Lawrence, Donald H. 69/2 Broadway, Fargo

LeBien, Wayne E. Fargo Clinic, Fargo

LeNlar, John I). Fargo Clinic, Fargo

Lewis, A. K. 606 Ash St., Lisbon

Lewis, T. H. 302 Black Bldg., Fargo

Lindsay, Douglas T. Fargo Clinic, Fargo

Long, William H. Dakota Clinic, Fargo

Lytle, Francis T. Fargo Clinic, Fargo

Macaulay, Warren L. Fargo Clinic, Fargo

Mazur, Bernard A. Dakota Clinic, Fargo

Melton, Frank M. Dakota Clinic, Fargo

Miller, Herbert H. 509)2 Dakota Ave., Wahpeton

Murray, James B.

Norum, Henry A.

Olson, Donald L.
Poindexter, Marlin H., Jr.
Poole, Ernest E.

Pray, Laurence G.

Rogers, Robert G.
Schleinitz, Fritz B.
Schneider, Joseph F.
Sedlak, Oliver A.

Shook, Lester D.

Smith, Bobby G.

Spier, J. J.

Stafne, William A.

Story, Robert D.

Swanson, Joel C.
Thompson, George R.
Travnor, Mack V.

Triggs, Perry O.

Ulmer, Robert J.

Urenn, Bernard M.

W itch, Abner
Wall, Wendell H.
Wasemiller, E. R.
Webster, William O.
Weible, Ralph D.

Wiltse, Glenn L.

Wold, Lester E.

Zai iner, Richard J.

Dakota Clinic, Fargo
Fargo Clinic, Fargo
.313 Black Bldg., Fargo
Fargo Clinic, Fargo
Sasse Bldg., Lidgerwood
Fargo Clinic, Fargo
Dakota Clinic, Fargo
Hankinson
114 Broadway, Fargo
Dakota Clinic, Fargo
Fargo Clinic, Fargo
136 S. 1st St., West Fargo
388 6th Ave. S., Fargo
Fargo Clinic, Fargo
Fargo Clinic, Fargo
407 Black Bldg., Fargo
Fargo Clinic, Fargo
Fargo Clinic, Fargo
Fargo Clinic, Fargo
Dakota Clinic, Fargo
Dakota Clinic, Fargo
502 Oak St., Lisbon
Wahpeton Clinic, Wahpeton
Wahpeton Clinic, Wahpeton
Fargo Clinic, Fargo
Dakota Clinic, Fargo
Wahpeton Clinic, Wahpeton
Fargo Clinic, Fargo
311 Black Bldg., Fargo

SECOND DISTRICT

Bryant, Emmett P.
Cook, Stuart f.

Corbett, Conner A.
Coultrip, Raymond L.,
Engesather, J. A. D.
Fawcett, John C.
Fawcett, Robert M.

Fox, William R.
Gilchrist, Milton R.
Gorrie, William A.
Hilts, George H.
Johnson, C. G.

Keller, Emil T.
Lazareck, I. L.
Longmire, L. T.
McBane, Robert D.
MacDonald, John A.
Mahoney, James H.
Munro, J. A.

Owens, Clarence G.
Palmer, Dolson W.

Pine, Louis F.
Sehwinghamer, E. J.
Seibel, Glenn W.

Sillier, William F.
Simpson, David F.
Stickelberger, Josephine

Terlecki, Jaroslaw
Toomey, Glenn W.
Vigeland, George N.
Voglewede, William C.

Lake Region Clinic, Devils Lake
Rolette

Lake Region Clinic, Devils Lake
Jr. McVille

Lakota

Lake Region Clinic, Devils Lake
Lake Region Clinic, Devils Lake
Johnson Clinic, Rugby
Rolla
Maddock
Cando

Johnson Clinic, Rugby
Johnson Clinic, Rugby
411 4th Ave., Devils Lake
411 4th Ave., Devils Lake
Towner
Cando

411 4th Ave., Devils Lake
Rolla
New Rockford
Cando

Lake Region Clinic, Devils Lake
New Rockford
New Rockford
Mann Block, Devils Lake
Edmore

S. 1524 Portland Ave.,

Apt. 102, St. Paul 4
Minnewaukan
Lake Region Clinic, Devils Lake
Johnson Clinic, Rugby
Carrington

OCTOBER 1958

431

THIRD DISTRICT

Adams, Paul V. Langdon

Andrews, Philip 1600 University Ave., Grand Forks
Bakewell, William E. Grand Forks Clinic, Grand Forks
Benson, T. 1600 University Ave., Grand Forks

Benwell, Harrv D. 4 Vi S. 3rd St., Grand Forks

Berger, Philip R. Grand Forks Clinic, Grand Forks

Campbell, Robert D. 4/2 S. 3rd St., Grand Forks

Cardy, James D. U.N.D., Grand Forks

Clark, Rodney Grand Forks Clinic, Grand Forks

Clayburgh, Bennie J. Grand Forks Clinic, Grand Forks
Colfer, Richard J. St. Michael’s Hosp., Grand Forks
Countryman, G. L. 1004 Hill Ave., Grafton

Culmer, A. E., Jr. 501 1st Natl. Bank Bldg.,

Grand Forks

Dailey, Walter C. 4/2 S. 3rd St., Grand Forks

Deason, Frank W. 643 Cooper Ave., Grafton

DeLaiio, Robert II. Northwood

Platen, Allred N. Edinburg

Frey, W elide W. Drayton

Glaspel, G. ]. Grafton Clinic, Grafton

Goehl, R. O. Grand Forks Clinic, Grand Forks

Graham, C. M. 1600 University Ave., Grand Forks

Graham, John II. 15)2 S. 3rd St., Grand Forks

Grinnell, Ernest L. Grand Forks Clinic, Grand Forks
Hardy, Nigel A. Minto

Harwood, T. II. U.N.D., Grand Forks

Haugen, C. O. Larimore

Haunz, E. A. Grand Forks Clinic, Grand Forks

Helgason, N. M. Cavalier

Hill, Frank A. Grand Forks Clinic, Grand Forks

|ensen, August F. 1600 University Ave., Grand Forks
Johanson, John F. Cavalier

Kaluzniak, Nicholas Langdon

Keig, William P., Jr. 1600 University Ave., Grand Forks

Kohlmeyer, A. C (in service)

Landry, L. H. . Walhalla

Leigh, James A. 716 4th Ave. S.,

East Grand Forks, Minn.
Leigh, Ralph E. Ill North 5th St., Grand Forks

Leigh, Richard H. 1600 University Ave., Grand Forks
McLeod, John Grand Forks Clinic, Grand Forks

Mahowald, Ralph E. 504 Valley Bank Bldg.,

Grand Forks

Mann, Hamish 1600 University Ave., Grand Forks

Meredith, William C . Drayton

Moore, J. H. Grand Forks Clinic, Grand Forks

Muus, Jacob M. McVille

M mis, O. Harold 502 Commercial Exchange Bldg.,

Grand Forks

Nelson, Wallace W. Grand Forks Clinic, Grand Forks
Nelson, William C. Grand Forks Clinic, Grand Forks
Osten, Taylor A. Michigan

O’Toole, James K. Park River

Painter, Robert C. Grand Forks Clinic, Grand Forks
Panek, A. F. Milton

Peake, F. Margaret 204 Widlund Bldg., Grand Forks
Peterkin, Frank D. Langdon

Pettit, Samuel L. Grand Forks Clinic, Grand Forks

Piltingsrud, Harold R. Park River

Porter, Charles B. Grand Forks Clinic, Grand Forks
Powers, William T. 4)2 S. 3rd St., Grand Forks

Prochaska, L. J. 517 1st Natl. Bank Bldg., Grand Forks
Ralston, Lloyd S. Grand Forks Clinic, Grand Forks

Rand, Charles C. Grafton State School, Grafton

Ruud, John E. 1st Natl. Bank Bldg., Grand Forks

Sandmeyer, John A. Grand Forks Clinic, Grand Forks

Silverman, Louis B. Grand Forks Clinic, Grand Forks

Teevens, William P. Grafton Clinic, Grafton

Thorgrimsen, G. G. 1600 University Ave., Grand Forks
Tompkins, C. R. 1004 Hill Ave., Grafton

Tsumagari, II. Y. (in service)

Turner, Robert C. Grand Forks Clinic, Grand Forks
Witherstine, William II. Ill N. 5th St., Grand Forks
Woutat, Philip 11. Grand Forks Clinic, Grand Forks

Youngs, Nelson A. Grand Forks Clinic, Grand Forks

Yury, Walter E. 1004 Hill Ave., Grafton

FOURTH DISTRICT

Amstutz, Kenneth N.
Anderson, Gordon D.

Ayash, John |.

Blatherwick, Robert
Boyle, John T.

Boyum, Lowell E.

Boyum, P. A.

Breslieh, Paul ].

Brown, Glenn W.

Cameron, Angus L.
Camilla, Pat
Devine, J. L„ Jr.

Devine, |. L., Sr.

Diduch, Alexander
Dormont, Richard E.
Erenfeld, Fred R.

Fischer, V. J.

Flath, M. G.

Floch, John L.

GammeU, Robert T.
Garrison, M. W.

Giltner, Lloyd A.

Goodman, Robert
Gozum, Ekrem
Greene, E. E.

Halliday, David J.
Halverson, C. H.
Hammargren, August F.
Hart, George M.
Hochhauser, Martin
Hoopes, Lorman L.
Hordinsky, Bohdan Z.
Huntley, Wellington B.
Hurly, William C.

Johnson, O. W.

Kermott, L. H., Jr.

Kermott, L. H., Sr.

Kitto, William
Kohl. D. L.

Kress, James W.

Lampert, M.T. 407

Northwest Clinic, Minot
Harvey

123 2nd Ave. S.E., Minot

Parshall

Garrison Clinic, Garrison
Harvey
Harvey

Northwest Clinic, Minot
Bottineau
Northwest Clinic, Minot
Mohall
Great Plains Clinic, Minot
Great Plains Clinic, Minot
Stanley

Northwest Clinic, Minot
617 2nd St. N.W., Minot
Medical Arts Clinic, Minot
Stanley
Mohall
Kenmare
Garrison Bldg., Minot
Medical Arts Clinic, Minot
Powers Lake
123 2nd Ave. S.E., Minot
Westhope
Kenmare

1st Natl. Bank Bldg., Minot
Harvey

Northwest Clinic, Minot
Garrison Clinic, Garrison
17A S. Main St., Minot
Drake

Great Plains Clinic, Minot
Medical Arts Clinic, Minot
Johnson Clinic, Rugbv
12A S. Main St., Minot
12A S. Main St., Minot
Northwest Clinic, Minot
123 2nd Ave. S.E., Minot
Garrison Clinic, Garrison
1st Natl. Bank Bldg.. Minot

Larson, Richard S.
Leonard, Kenneth O.

London, Carl B.
McArdle, John S.
McCannel, Archie D.
McCullough, William F.
McDougall, James R.
Malvey, Kenneth P.
Manzanero, F. M.
Naegeli, Frank D.
Nelson, Leslie F.

Olnt, Harry A.

Olson, Burton G.
Richardson, Gale R.
Rowe, Paul II.

Seiffert, G. S.

Shea, Samuel E.

Velva

(in service) Garrison Clinic,

Garrison
Northwest Clinic, Minot
Great Plains Clinic, Minot
505 Main St. S„ Minot
Bottineau
214 S. Main St., Minot
Bottineau
McCannel Clinic, Minot
Northwest Clinic, Minot
Bottineau
Kenmare
McCannel Clinic, Minot
St. Joseph’s Hospital, Minot
Northwest Clinic, Minot
Northwest Clinic, Minot
McCannel Clinic, Minot

432

THE JOURNAL-LANCET

Sorenson, A. R.
Sorenson, Roger
Towarnicky, Marvin |.
Uthus, O. S.

Vaaler, Raymond A.
Wall, Willard W.
Wallis, Marianne
Wilson, Herbert T. . . .

Medical Arts Clinic, Minot
Medical Arts Clinic, Minot
Fessenden
21M 2nd Ave. S.E., Minot
Great Plains Clinic, Minot
Northwest Clinic, Minot
St. Joseph’s Hospital, Minot
New Town

FIFTH DISTRICT

Christianson, Guilder
Goven, John W.

Harris, T. A.

Klein, C. J.

Macdonald, Alexander C

Macdonald, Neil A.
Merrett, J. P.
VanHouten, J.

Wakefield, Kenneth M.

117 N.W. 3rd, Valley Citv
117 N.W. 3rd, Valley City
Cooperstown
117 N.W. 3rd, Valley City
130 Central Ave'. S„ '
Valley City
130 Central Ave. S., Valley City
117 N.W. 3rd, Valley City
105 Main St. W„ Valley City
Cooperstown

SIXTH DISTRICT

Anderson, F. E. Underwood

Anthony, John Wishek

Arneson, Charles A. Missouri Valley Clinic, Bismarck
Baumgartner, Carl J. Quain & Ramstad Clinic, Bismarck
Benson, O. T. 1737 Whitley Ave., Hollywood, Cal.

Berg, H. Milton Quain & Ramstad Clinic, Bismarck

Berg, Roger M. Quain & Ramstad Clinic, Bismarck

Bertheau, Herman J. Linton

Blumenthal, Philip L. 107 1st Ave. N.W., Mandan

Bodenstab, William H. 520 Mandan St., Bismarck

Boerth, E. H. Quain & Ramstad Clinic, Bismarck

Brink, Norvel O. Quain & Ramstad Clinic, Bismarck

Buckingham, T. W. 405/2 Broadway, Bismarck

Cartwright, John T. Missouri Valley Clinic, Bismarck
Cleary, Joseph W. Missouri Valley Clinic, Bismarck
Curiskis, A. A. Elgin

Dahl, Phillip O. Missouri Valley Clinic, Bismarck

Diven, Wilbur L. 402/2 Main, Bismarck

Eriksen, Johan A. Quain & Ramstad Clinic, Bismarck
Fisher, Albert M. 922 8th St., Bismarck

Freise, Paul W. Quain & Ramstad Clinic, Bismarck

Froeschle, Rudolph P. Hazen

Gaebe, Otto C. New Salem

Girard, Bernard A. Beulah

Goughnour, Mvron W. Capital City Clinic, Bismarck
Gregware, Peter R. Quain & Ramstad Clinic, Bismarck
Griebenow, Frederick 905 9th St., Bismarck

Gutowski, Franz Wishek

Heffron, M. M. 412)2 Main, Bismarck

Henderson, Robert W. Capital City Clinic, Bismarck
Hetzler, Arnold E. 104 3rd Ave., N.W., Mandan

Ieenogle, Grover D. Capitol Bldg., Bismarck

Jacobson, M. S. Elgin

Johnson, K. J. Quain & Ramstad Clinic, Bismarck

Johnson, M. J. E. Quain & Ramstad Clinic, Bismarck

Johnson, Paul L. Quain & Ramstad Clinic, Bismarck

Kalnins, Arnold Washburn

Kling, Robert R. Quain & Ramstad Clinic, Bismarck
Kuplis, Heralds Turtle Lake

Larson, Leonard W. Quain & Ramstad Clinic, Bismarck
Levi, Wesley E. 1215 1st St. N.W., Bismarck

Lindelow, O. V. Missouri Valley Clinic, Bismarck

Lipp, George R. 405/2 Broadway, Bismarck

Lommen, M. A. K. Capital City Clinic, Bismarck

McGee, William J. 104 Missouri Drive, Riverdale

Montz, Charles R. Quain & Ramstad Clinic, Bismarck
Nuessle, Robert F. Quain & Ramstad Clinic, Bismarck

Nugent, Milton E. Quain & Ramstad Clinic, Bismarck
Oja, Karl F. Ashley

Orchard, W. J. 112 Hickory Ave. E., Linton

Orr, August C. Capital City Clinic, Bismarck

Owens, P. L. Missouri Valley Clinic, Bismarck

Perrin, Edwin D. Quain & Ramstad Clinic, Bismarck

Peters, Clifford H. Quain & Ramstad Clinic, Bismarck

Peterson, Alice II. State Health Dept., Capitol Bldg.,

Bismarck

Pierce, W. B. Quain & Ramstad Clinic, Bismarck

Quain, Eric P. 2075 Raynor St., Salem, Oregon

Radi, Robert B. Quain & Ramstad Clinic, Bismarck
Samuelson, Albert F. Quain & Ramstad Clinic, Bismarck
Schoregge, Charles W. Quain & Ramstad Clinic,

Bismarck

Schoregge, Robert D. Quain & Ramstad Clinic,

Bismarck

Smeenk, H. Pieter Quain & Ramstad Clinic, Bismarck
Smith, Cecil C. 101 Collins Ave., Mandan

Smith, Clyde L. Missouri Valley Clinic, Bismarck

Spielman, George PI. 305 1st Ave. N.W., Mandan

Thompson, Arnold Quain & Ramstad Clinic, Bismarck
Tudor, Robert B. Quain & Ramstad Clinic, Bismarck
Vinje, Edmund C. Hazen Clinic, Hazen

Vinje, Ralph 405 E. Broadway, Bismarck

Vonnegut, Felix F. Linton

Waldschmidt, R. H. Quain & Ramstad Clinic, Bismarck

Walter, Paul A. F. Hazen

Weyrens, P. [. Hebron

Zukowsky, Anthony Ozone Bldg., Steele

SEVENTH DISTRICT

Arzt, Philip G. 401 3rd St. S.E., Jamestown

Beall, John A. Medical Arts Clinic, Jamestown

Cameron, D. Murray Hettinger

Craychee, Walter A. 205 Union Ave., Oakes

Dagg, Earl W. Ellendale

Elsworth, John N. DePuy-Sorkness Clinic, Jamestown
Fandrich, Harry A. Carrington

Fergusson, Victor D. Edgeley

Freeman, John G. State Hospital, Jamestown

Gronewald, Tula W. State Hospital, Jamestown

Hayward, M. Alan 414 100th N.E., Bellevue, Wash.
Hieb, Edwin O. DePuy-Sorkness Clinic, Jamestown
Hogan, Clifford W. DePuy-Sorkness Clinic, Jamestown
Jansonius, J. W. Medical Arts Clinic, Jamestown

Larson, Ernest J. DePuy-Sorkness Clinic, Jamestown
Lucy, Robert E. DePuy-Sorkness Clinic, Jamestown
Lynde, Roy Ellendale

McFadden, Robert L. DePuy-Sorkness Clinic,

Jamestown

Martin, Clarence S. Kensal

Melzer, Simon W. Woodworth

Miles, James V., Jr. DePuy-Sorkness Clinic, Jamestown
Nierling, Richard D. DePuy-Sorkness Clinic, Jamestown
Oster, Ellis Ellendale

Pederson, Thomas E. DePuy-Sorkness Clinic, Jamestown
Saxvik, Russell O. State Hospital, Jamestown

Sorkness, Joseph DePuy-Sorkness Clinic, Jamestown

Swenson, John A. DePuy-Sorkness Clinic, Jamestown

Tripp, Harry D. Florida State Hospital,

Chattahoochee, Florida
Turner, Neville W. LaMoure

Van der Linde, John M. Medical Arts Clinic, Jamestown
Van Houten, Richard W. 301 Union Ave., Oakes

Woodward, Robert S. DePuy-Sorkness ClinD,

Jamestown

Young, John H. State Hospital, Jamestown

OCTOBER 1958

433

EIGHTH DISTRICT

Borrud, Chester C.
Craven, John P.
Craven, Joseph D.

Ellis, Gordon E.
Fennell, William L.
Hagan, Edward J.
Johnson, A. K.

Johnson, P. O. C.
Keller, John M.
Knobloch, W. H., Jr.
Korwin, J. J.

Lamal, Andre H.

Lund, C. M.

McPhail, C. O.

Pile, Duane F.

Sathe, Andrew G.

Skjei, Donald E.
Strinden, Dean R.
Walker, H. Charles, Jr.
Wright, Willard A.

Harmon Park Clinic, Williston
411 Main St., Williston
411 Main St., Williston
Harmon Park Clinic, Williston
Crosby

411 Main St., Williston
Williston Clinic, Williston

Watford City

Williston Clinic, Williston

Tioga

120 Main St., Williston
Watford City
Williston Clinic, Williston
Crosby
Crosby

Harmon Park Clinic, Williston
Williston Clinic, Williston
Harmon Park Clinic, Williston
411 Main St., Williston
Williston Clinic, Williston

NINTH DISTRICT

Buckingham, W. M.
Bush, Clarence A.
Dukart, C. R.
Dukart, Ralph J.
Foster, Keith G.
Gilliland, Robert F.
Gilsdorf, Amos R.
Guloien, Hans E.

Elgin

Beach

Dickinson Clinic, Dickinson
Dickinson Clinic, Dickinson
109 W. 7th St., Dickinson
Dickinson Clinic, Dickinson
Dickinson Clinic, Dickinson
Dickinson Clinic, Dickinson

Gumper, Arnold |.
Hanewald, Walter C.
Hankins, Robert E.

Hill, S. W.

Hilts, Joseph A.
Knickerbocker, W. J.
Larsen, H. C.
Maercklein, Otto C.
Martin, Gladys E.
Ordahl, Norman B.
Raasch, Richard F.
Reichert, D. J.

Reichert, H. L.

Rodgers, R. W. R.
Schumacher, William A.
Smith, O. M.

Spear, A. E.

Thom, Robert C.

Tosky, Julian

109 W. 7th St., Dickinson
Richardton
Mott

Regent

Hettinger
Hettinger
109 W. 7th St., Dickinson
Mott

Dickinson Clinic, Dickinson
109 W. 7th St., Dickinson
Dickinson Clinic, Dickinson
24 W. Villard, Dickinson
24 W. Villard, Dickinson
109 W. 7th St., Dickinson
( formerly at Hettinger)
Dickinson
610 1st Ave. W„ Dickinson
Bowman
Hebron

TENTH DISTRICT

Dekkcr, Omar D.
Kjelland, A. A.
LaFleur, H. A.

Little, James M.
Little, Roy C.
McLean, Robert W.
Mergens, Daniel N.
Rosenberg, Mervin
Vandergon, Keith G.
Waydeman, H. B.

Finley
Hatton
Mayville
(in service) Mayville
Mayville
Hillsboro
Hillsboro
Northwood
Portland
Hunter

434

THE JOURNAL-LANCET

TWELFTH ANNUAL MEETING

WOMAN'S AUXILIARY TO THE NORTH DAKOTA STATE MEDICAL ASSOCIATION
Minot, North Dakota, May 3, 4, 5, and 6, 1958

The twelfth annual meeting of the Woman’s Auxiliary
to the North Dakota State Medical Association was held
in the Sky Room, Clarence Parker Hotel, Monday, May 5,
1958, at 10:00 a.m. The meeting was formally opened
by Mrs. ). D. Cardy, president.

The pledge of loyalty was given by Mrs. V. |. Fischer,
state president-elect, and repeated in unison by the mem-
bers present.

Invocation was given by Mrs. J. M. Van der Linde,
first vice-president.

Mrs. [. D. Cardy introduced our honored guest, Mrs.
M. A. Gold, of Butte, Montana, fourth vice-president of
the Woman’s Auxiliary to the A.M. A.

Mrs. Oliver Uthus, president of the Northwest District,
gave the address of welcome. The response was given
by Mrs. B. A. Mazur, president of the First District.
Mrs. R. W. Rodgers was appointed parliamentarian.

The roll was called bv the secretary, Mrs. |. W. Jan-
sonius, and the following were present:

Mrs. J. D. Cardy, president; Mrs. V. J. Fischer, president-elect;
Mrs. J.M. Van der Linde, first vice-president; Mrs. R. F. Gilliland,
second vice-president; Mrs. R. W. McLean, treasurer; Mrs. J. W.
Jansonius, recording secretary; and Mrs. J. J. Stratte, correspond-
ing secretary.

State chairmen: Mrs. Nl. M. Heffron, press and publicity; Mrs.
Robert Hankins, editor; Mrs. Thomas Longmire, public relations;
Mrs. Clyde Smith, legislation; Mrs. Henry Kermott, Bulletin; Mrs.
R. W. Rodgers, A.M.E.F.; Mrs. Samuel Shea, mental health; Mrs.
L. L. Hoopes, safety; Mrs. J. D. Craven, student loan fund; and
Mrs. J. H. Mahoney, resolutions.

District presidents: Mrs. B. A. Mazur, Fargo; and Mrs. William
Kitto, Minot.

Delegates: Mrs. O. A. Sedlak, Fargo; Mrs. M. H. Poindexter,
Fargo; Mrs. D. J. Halliday, Kenmare; Mrs. B. Z. Hordinsky, Minot;
Mrs. Dorothy Gilchrist, Devils Lake; Mrs. R. L. NlcFadden and
Mrs. R. D. Nierling, Jamestown; and Mrs. Ralph Mahowald,
Grand Forks.

Councillors: Mrs. O. M. DeMoully, Bismarck; Mrs. Gunder
Christianson, Valley City; and Mrs. L. H. Reichert, Dickinson.

Mrs. R. F. Gilliland, second vice-president, gave the
“In Memoriam,” which is quoted below:

“It is with a great deal of sadness and an equally great
sense of loss that we bring to our attention the loss of
1 auxiliary member during the past year. Mrs. A. F.
Panek, of Milton and the Grand Forks District Medical
Auxiliary, passed away at the age of 71 on April 2, 1958.

“Our sympathy goes out to Dr. A. F. Panek, his son
and 2 daughters who survive Mrs. Panek, and also to
other members of her family.

“Mrs. Panek had made her home in or near the Milton
community since 1906. She married Dr. A. F. Panek
in Park River in 1921. Besides her work in the auxiliary,
she was a past president of the Milton American Legion
Auxiliary and a member of the Rova! Neighbor Lodge,
St. Clothide’s Catholic Church, and the St. Clothide’s
Altar Society.

“Let us of the Woman’s Auxiliary of the North Dakota
State Medical Association at this time briefly pause to
honor and cherish the memory of our departed friend
and member. May we ever be thankful for having had
her among us and leaving us the imprint of her per-
sonality and greatness.”

Motion was made by Mrs. J. M. Van der Linde that
the minutes of the eleventh annual meeting be accepted
as printed in the October 1957 issue of The Journal-
Lancet.

Mrs. Robert McLean then read the treasurer’s report

and asked that all outstanding bills be presented as soon
as possible.

Treasurer's Report

Bank balance: September 1957 $1,321.02

Receipts:

Dues: 302 members at $4.00 $1,208.00

1 member in arrears 4.00

Sophomore student loan fund 2,089.46

Student loan memorial given by

Mrs. Mary Weible 20.00

Sale of Handbooks — 4 at $ .2.5 . 1 .00

Convention contribution from North

Dakota State Medical Association 100.00

Registration (Minot convention)

85 members at $1.00 8.5.00

Convention luncheons (2) and banquet 388.10

$3,895.56 3,895.56

Total receipts $5,216.58

Disbu rsem en ts :

Dues to National: 302 members at $1.00 302.00

1 member in arrears 1.00

Sophomore student loan fund 2,089.46

President’s expenses 149.60

Mrs. J. Jansonius (Chicago conference) 8.5.64

President elect’s expenses ( Chicago

conference) 99.29

Newsletter and stationery

Bismarck Tribune Co. .51.00

Newsletters: October and December 1957
and February and April 1958 148.51

Used file cabinet 34.05

2,960.55 2,960.55

2.00
8.17
3.20
8.61

3.00

4.00
7.75

36.73 36.7.3

Miscellaneous:

L. G. Balfour (2 president’s pins) 14.66

Grand Forks Floral (M. Fremming) 10.00

Bank fees 4.78

29.44 29.44

8.5.65

7.85

1.50.54

14.5.60

117.41

10.20

7.71

2.55

1.53

7.91

11.60

9.13

557.68 5.57.68

Total expenditures $3,584.40

Bank balance: June 14, 1958 $1,732.15

Mrs. J. D. Cardy then presented Dr. R. W. Rodgers,
president of the North Dakota State Medical Association.
He extended greetings from the medical society, praised
us on our achievements, and suggested that we become
better informed about Blue Shield and that we have one

Convention expenses:

Clarence Parker Hotel:
Luncheon

Pre-convention board meeting
Banquet

Riverside Lodge, brunch
Valkers Green House
Maytag Electric
Minot Drug Co.

Saunders Drug
Service Printers
Lowes Printing ( tickets )

Place Cards, favors, etc.
Elingson’s Department Store

Standing and special committees:
Public relations
Press and publicity
News Views and Cues editor
Correspondence secretary
Nurse recruitment
Treasurer

Organization and membership

OCTOBER 1958

435

meeting at the county level concerning what Blue Shield
means in the prevention of accepting socialized medi-
cine. He suggested that we read Medical Economics to
acquire a better understanding of the social and eco-
nomic problems facing medicine.

Mrs. |. D. Cardy then told us of the wonderful rec-
ord of membership in the Student American Medical
Association Auxiliary and that our own Student A.M.A.
Auxiliary was listed among the first in the nation to re-
ceive its charter.

The following reports of state officers and chairmen
were then given. The president’s report was the first to
be presented and is recorded in the September 1958 issue
of The Journal-Lancet under Proceedings of the House
of Delegates.

Organization and Membership Report
1957-1958

Number of district medical societies in North Da-
kota: 10.

Number of district medical auxiliaries in North Da-
kota: 10.

Number of new districts organized during the past
year : none.

Total number of paid auxiliary memberships: 290.

Mrs. Mason G. Lawson, past president of the Wom-
an’s Auxiliary to the American Medical Association, is
our honorary member.

To the district presidents, organization chairmen, and
treasurers, who by their diligence and dedication have
helped retain our previous membership and added new
members, I wish to express my sincere thanks.

Mrs. V. (. Fischer, Chairman

Program Report

Our theme for 1957-1958 was “Health is a Joint En-
deavor. From reports received, it would seem that our
North Dakota auxiliaries had worked all year to prove
this theme to be correct.

North Dakota participated in the national essay con-
test for the first time this year. In most districts, the
response was excellent and the general consensus of
opinion is that a contest such as this is worth backing.

We are well aware of the wide margin of difference
between our auxiliaries as to number of members and
scope of activity. What an auxiliary with a large mem-
bership can do relatively easily along the lines of fund
raising or special projects, a smaller membership cannot
undertake. Our cancer program is a case in point. Each
auxiliary was instructed to work out for itself the extent
of its participation. Fargo and Grand Forks are actively
engaged in the cancer program, but the smaller auxil-
iaries, for the most part, are limiting their activities to
an offer of assistance to the county society should the
need arise.

Our Future Nurses’ Clubs now number 3, with Dickin-
son and Mott joining Jamestown. The Jamestown club
now numbers 29 members, 10 of whom plan to enter
nurses’ training in the fall.

As a state, we are not supporting Today’s Health
magazine. This is the medical profession’s own magazine.
It contains factual information; it contains educational
articles for the layman and deserves better support
from us.

With the alarming rise in automobile accidents, our
safety program should be made active in each of our
auxiliaries, regardless of its size. With such wonderful
material as that which has come from our safety chair-
man, Mrs. Hoopes, setting up this program should prove
no problem.

If we plan to keep the government from controlling
our medical schools, we must give greater support to
the A.M.E.F. and student loan funds. We are support-
ing them but not strongly enough.

Our membership has dropped from 301 to 290. After
some investigation, it appears that most of these lost
members are widows of physicians. Since the medical
population of the state is growing, we should see an in-
crease in our membership this next year. Extending a
personal invitation to these newcomers to attend a meet-
ing of the local auxiliary is most important. We need
them and firmly believe they need us.

Mrs. J. M. Van der Linde, Chairman

Civil Defense Report

As there were no prepared outlines for state auxiliaries
from the national chairman this year, I outlined a pro-
gram of 3 objectives for our state civil defense program
for 1957 and 1958 and sent the following requests to
the 10 district civil defense chairmen in November ask-
ing for a reply:

1. Contact your local civil defense chairman IMME-
DIATELY, giving him your name, address, and
telephone number. Inform him of our interest and
program in civil defense. Ask him to get in touch
with you for any assistance he may need and that
you will do everything possible to provide workers
from the auxiliary and create the much needed in-
terest. You might also give him a typed list of
names, addresses, and telephone numbers of auxil-
iary members willing and able to work. But, be
sure you have the o.k. from each member whose
name you are submitting.

2. Urge each member to place a first-aid kit in home
and car. Follow up as to the number doing so.

3. Urge each member to take courses in home nursing
or first aid. Follow up the same as objective 2.

I received replies from 5 of the district civil defense
chairmen. They had all stressed objectives 2 and 3.
However, it was impossible to fulfill objective 1 in areas
where there is no organized civil defense program.

In localities in which the civil defense program is or-
ganized and operating, our auxiliary members are very
active and doing their share. But, in areas where there
is no organization, our members have found it difficult
or impossible to assume responsibilities in civil defense.
North Dakota, I feel, for the first time is becoming civil
defense conscious, and, within the next few years, the
state should be well organized, and our members will
then be able to cooperate and accomplish more.

Mrs. R. F. Gilliland, Chairman

Safety Report

The safety program outlined by the National Safety
Council has seen little activity in our district auxiliaries
this year, but it is hoped that this baby of our family
will gather momentum as time goes by.

Definite program materials and lists of available visual
aids, though eventually sent out to all the district aux-
iliaries, were slow to come in at the beginning of the
year, and some auxiliaries may have had their year’s
planning done before these were available. Another rea-
son for the lack of activity in this program max' be the
fact that North Dakota already requires high school
driver education in its schools, although most of that
training is confined to the classroom rather than the pre-
ferred “behind the wheel” training. Chemical tests for
intoxication are legalized procedures in our state, but
safety in auto design and equipment still needs the all
out promotion of every auxiliary.

436

TIIE JOURNAL-LANCET

The Northwest District had planned a program on
safety for their March meeting, but, unfortunately, due
to severe weather conditions, that meeting had to be
cancelled. At the request of our state president, a sketch
on safety was published in our News, Views, and Cues
at the first of the year to acquaint all members with the
new safety program.

In April, Mrs. |. D. Cardy represented our organiza-
tion at President Eisenhower’s Conference on Traffic
Safety.

Safety problems were considered so urgent that the
President of the United States was requested to form a
committee. Surely then, the safety program as outlined
bv our National Safety Council deserves our support.
Now that the safety goals are familiar to all. we should
expect each district president for 1958 and 1959 to es-
tablish a place for safety in her programming at the very
beginning of her fall term.

Mrs. Lorman L. Uoopes, Chairman

Mrs. Cardy stated how much she enjoyed the Traffic
Safety Conference, and that all recommendations would
go to the governor.

Today's Health

The following report is based on figures from the Chi-
cago office of Today’s Health for the purpose of uniform
comparison, since a number of counties did not send in
reports.

County

Quota

Credits

Percentage

First district (Cass)

65

4

6%

Devils Lake (2nd district)

18

—

—

Grand Forks district

52

32

62%

Kotana

18

23

128%

Northwest district

24

33

137%

Sheyenne Valley

5

—

—

Sixth District ( Burleigh )

61

19

31%

Southeastern district ( Stark )

23

25

108%

Stutsman

21

8

38%

Traill - Steele

9

—

—

Totals

296

144

48%

Congratulations are heartily given to the £

! districts

who reached over a 100 per
west, Kotana, and Stark.

cent

quota: name]

y. North-

No recommendation from

any

district has

been re-

ceived as to how our state can meet its quota for Today’s
Health. However, one possibly may be to incorporate
the tee of one subscription into each member’s dues. A
project of each county for the coming year may also be
written to contact all medical and dental personnel in its
area for subscriptions.

Mrs. Nevile W. Turner, Chairman

Bulletin Report

During the period Inly 1, 1957, to April 15, 1958,
there were 69 subscriptions to the Bulletin, which is the
official publication of the Woman’s Auxiliary to the
American Medical Association.

Mrs. Henry Kermott, Chairman

Public Relations Report

This year, as in the past, the members of the North
Dakota medical auxiliary have been busy in the field of
public relations. In every community where there is a
doctor, that doctor’s wife has been busy in community
projects. Many of them are active in the hospital auxil-
iaries, health drives, Red Cross, and scouting. Several
of our members are presidents and committee workers in
their P.T.A. groups. One is a member of her local park
board. Another active auxiliary member directed a com-
munity minstrel show, and still another is a particularly

active volunteer worker in the Red Cross and Gray
Ladies.

Teas, fashion shows, and dances were high on the list
this year as fund raising projects for the medical student
loan fund. Another big project for us this year was the
American Association of Physicians and Surgeons essay
contest. Our first year in this nationwide contest saw 6
out of 10 districts with essays to submit to the state
judges. Several of the remaining districts placed the
material in the schools but had no essays completed.
The prizes for the winning essays were presented during
medical education week.

Contributions to A.M.E.F. have continued, and med-
ical recruitment has received attention witli Future
Nurses Clubs, teas, and scholarships.

Mrs. Thomas Longmire, Chairman

Mrs. Longmire suggested that any individual contri-
bution to community service should be sent to the Pub-
lic Relations chairman, such as anything we do at science
fairs, in rehabilitation, crippled children’s clinics, hospi-
tal auxiliaries, and so on.

Press and Publicity Report

The press and publicity work done for our auxiliary
during the past year has been accomplished by a com-
mittee of 2 members: namely, News, Views and Cues
editor, Mrs. Robert E. Hankins, of Mott, and your press
and publicity chairman.

Through the combined efforts of the editor and the
chairman, 4 issues of News, Views and Cues were pub-
lished and appeared in October, December, February,
and April. The editor set deadlines; handled correspond-
ence with the councillors regarding district news; re-
ceived, edited, and condensed the district news; and also
planned the general composition of our publication. As
chairman, I assisted the editor by conferring by mail
and phone with our state president, who is our publica-
tions advisor, and by following up these conferences with
letters to our state board members to procure the timely
messages and cues we wanted to publish to boost or
explain certain auxiliary projects. Miscellaneous an-
nouncements, profile sketches, and reports not included
in the other state chairmen’s messages appeared in a
column called “Press and Publicity Box.” This column
was a regular feature of each issue. I also assisted by
acting as business and circulation manager.

Pursuant to a proposal made, discussed, and approved
at the last fall state board meeting, a printed cover made
from the plate used for our printed tenth anniversary
issue was added to the News, Views and Cues. A three-
year supply of covers was purchased, and it is expected
that as we thus discontinue the practice of mimeograph-
ing our first page on a costly letterhead, with the ensuing
and unavoidable waste from mimeograph machine er-
rors, our stationery costs will be reduced.

A mailing list of names and home addresses of the
wives of all doctors who are members of the North Da-
kota State Medical Association, plus those of the new
doctors who moved into the state, was kept as up-to-
date as possible through conferences with the state med-
ical association office and through correspondence with
the district councillors. Copies of this list were sent to
our president-elect because she is also organization chair-
man and to our News, Views and Cues editor. Copies
can also be given to any other chairmen who need and
request them.

News, Views and Cues was mailed to all the in-state
doctors’ wives on our mailing list and also to the ed-
itors of the official auxiliary publications of other states
and to our national president, president-elect, national

OCTOBER 1958

437

publications chairman, national executive secretary, and
to the A.M.A. Public Relations Department research
librarian. This mailing list has steadily increased from
485 names in April 1957 to 517 as of April 1958. Only
59 of these are out-of-state names. Our publication costs
us approximately $.08 per copy.

News from 3 of our districts, Grand Forks, Sixth, and
Southwestern, appeared in every issue. All districts have
sent in news for at least 2 of the 4 issues; therefore,' we
have had news from at least 6, and often 8 districts, in
each issue. The district councillors and publicity commit-
tee members, acting as reporters, kept us informed about
district meetings, newcomers, absentees, births, deaths,
weddings, travel, our members’ accomplishments in com-
munity service, and the accomplishments, also, ot the
medical offspring.

We are indebted to 7 state chairmen; to our state pres-
ident and president-elect; to Dr. Starcher, president of
the University of North Dakota; and to all district presi-
dents for special articles or information contributed to
News, Views and Cues this year.

The publication of News, Views mid Cues was not
our only publicity project this year. Forty-three mimeo-
graphed copies of a news release concerning the AAPS
essay contest were prepared at the request of our public
relations chairman. This news release was sent directlv
to 15 newspapers, and the remaining copies were given
to district essay contest chairmen to be distributed to
other newspapers or interested individuals. Clippings
from 14 newspapers have been collected thus far and
indicate that many newspapers gave us very adequate
cooperation. The district contest chairmen handled the
task of writing up the news of their district winners for
their local newspapers, and a clipping from the Sunday
Fargo Forum indicates that at least First District and
Stutsman District procured excellent coverage on the
final phase of their district contest.

Our state medical association has no chairman whose
duties parallel those of our press and publicity chairman
because its executive secretary, Mr. Limond, handles the
editing of its newsletter and newspaper publicity and
any decisions necessary are made by its committee on
public relations. We have done all of our auxiliary pub-
licity work through and with advice from Mr. Limond’s
office.

In the future, it woidd be well to observe the sugges-
tion of our editor that if all districts would follow the
example of the district which has a volunteer publicity
committee of 3 members who call all other members in
their district to solicit news, the work of the editor and
councillors woidd be made easier and more effective.
Moreover, the possibilities for improving and expanding
our publicity are limited only by our need for more
members, more money, and more volunteer assistants.

Mrs. M. M. Heffron, Chairman

Motion was made by Mrs. R. L. McFadden to accept
the recommendation that we add at least 1 new mem-
ber to our press and publicity committee, the new mem-
ber to be Gladys Arneson. The motion was seconded
by Mrs. Clyde Smith and carried.

Motion was made by Mrs. Longmire and seconded by
Mrs. Craven that if a district has a sufficient member-
ship, a publicity committee should be established to
work with the councillor to obtain news for press and
publicity. Motion was carried.

Mental Health Report

Although no definite mental health program has been
established by the state medical association this year, an

outline of suggested program activities received from the
National Committee on Mental Health was sent to each
county auxiliary. Included with this outline was a rec-
ommendation regarding the observance of Mental Health
Week scheduled for April 27 to May 3, 1958.

The purpose of Mental Health Week is to mobilize
public interest and concern in the problem of mental
illness and to channel this interest into action with and
through the Mental Health Association. The slogan is,
“With Your Help, the Mentally 111 Can Come Back."
It stresses the hopeful aspect of the problem and urges
the public to translate this hope into action in order that
thousands of mentally sick people may be restored to
their families and communities.

The 4 rallying points for Mental Health Week are:
( 1 ) improved care and treatment of mental hospital pa-
tients, (2) expanded services for early detection and
treatment, (3) adequate rehabilitation for the recovered
mental patient, and (4) research.

It is realized that our activities are limited in many
ot the suggested projects. However, it was recommended
that we support Mental Health Week in any of the ways
mentioned that are best suited to each district auxiliary.

No record is available regarding how many county
auxiliaries had a program at one of their meetings on
mental health, since this report is being submitted pre-
vious to Mental Health Week.

Mrs. Samuel E. Shea, Chairman

Legislation Report

An attitude ot watchful waiting toward the Forand
bill HR-9467 seems to have been the chief legislative
activity of the medical auxiliary since the legislative
report of last year. The thinking of the A.M.A. in its fight
against the Forand bill has been a reflection of the think-
ing of Congress and the country as a whole since the
introduction of the bill on August 27, 1957.

At the North Central Medical Conference in Minne-
apolis in November 1957, we were alerted to the dangers
of the Forand bill, its provisions, and possible consequen-
ces. In brief, the bill would authorize extension of the
Social Security Act to provide hospitalization for sixty
days and sixty days of nursing home care per year for
OASI beneficiaries (retired workers and their benefi-
ciaries and survivors). Financed also is necessary sur-
gical care by American Board of Surgery members or
members of the American College of Surgeons. All care
must be given in institutions which have entered into
an agreement with the government.

Sputnik No. 1 gave us a temporary respite, since it
was felt Congress would concentrate on defense and
guided missile development. However, now that anti-
recession legislation has become more prominent, there
is danger that the Forand bill may be brought out of
the Ways and Means Committee accompanying the Hill-
Burton hospital bill.

The reasons why the Forand bill should not be passed
are many, varied, and vital. Some of those considered
by the A.M.A. to be most urgent are: ( 1 ) it would mean
higher taxes and less take home pay; ( 2 ) it could bank-
rupt the social security program; (3) demands by others
for similar benefits could lead to total socialized medi-
cine; ( 4 ) government regulation of professional fees,
wages, and prices, would be introduced in the United
States; (5) communities would be threatened with a
shortage of hospital beds; ( 6 ) manv aged persons would
become unduly concerned with their health; and (7)
beneficiaries under law would be restricted in their choice
of hospital and physician.

438

THE JOURNAL-LANCET

Antidotes to the Forand bill are being formulated by
the A.M.A. to eliminate the necessity of such a bill.
Among the points suggested for aging care are: (1)
extension of voluntary health insurance to eliminate age
limits and (2) development of adequate facilities tor
care of the aged, such as adding chronic disease wings
to hospitals, building nursing homes with FHA help,
developing foster homes for aged persons, and forming
“Golden Age” clubs with meaningful meetings.

We auxiliary members and our husbands were given
a most practical suggestion at a meeting called by Mr.
Joseph Miller of the A.M.A. Committee on Hospitals for
Legislation Committee members of the N.D.S.M.A. and
auxiliary members interested in legislation. At this meet-
ing, Mr. Lvle Limond, executive secretary of the N.D.
S.M.A., commented that he had spoken to one of our
national congressmen who said he was often asked for
favors by the medical profession but that he could not
remember when any physician helped him in his cam-
paign. Perhaps the best or only answer to the problem
of congressional cooperation is increased political activ-
ity on the part of physicians and their wives.

We hope that the meetings of the legislative key men
and women will lead to further cooperation in the future.
At both the North Central Medical Conference and the
special legislation meeting in Bismarck, the importance
of auxiliary assistance was mentioned and the impres-
sion given that much greater use would be made of the
auxiliary in the future.

Mrs. Clyde Smith, Chairman

Recruitment Report

The recruitment program in North Dakota has con-
tinued much the same as last year and includes all allied
medical careers.

Films have been shown at schools, Future Nurses’
Clubs, hospital guilds, and auxiliary meetings. Informa-
tion on scholarships has been given to students, P.T.A.’s,
hospital guilds, and auxiliary members. Tours have been
conducted through hospitals, schools of nursing, and
medical laboratories. Career days (or nights) still seem
to be the most successful method of recruitment.

Mrs. A. Thompson of Bismarck displayed recruitment
literature and talked on nursing at the E.L.C. Luther
League Camp.

The chairman prepared 14 posters on health careers,
schools of nursing in the state, career days, and so on.
These were displayed at the state medical meeting and
at the state nurses’ convention last October. They are
available to districts for display purposes.

One previously organized Future Nurses’ Club con-
tinues in the state and is a very active group under the
capable direction of Mrs. John Young, Jamestown. Two
new Future Nurses’ Clubs have been formed: 1 in Dick-
inson under guidance of Mrs. Amos Gilsdorf and 1 in
Mott under direction of Mrs. R. Hankins.

October 9 and 10, 1957, Mrs. John Young and the
chairman attended the state meeting of the Nurses’ As-
sociation in Minot and appeared on a panel on Future
Nurses’ Clubs. The panel was comprised of representa-
tives of the National League for Nursing, State Nurses’
Association, Medical Auxiliary, Board of Education, and
Future Nurses’ Clubs (an advisor and a student mem-
ber). This was a wonderful opportunity to promote pub-
lic relations and also to increase the cooperative spirit
already existing between the medical auxiliary and the
Nurses’ Association. It would take all the superlatives of
praise to express the attitude of the group after hearing
the enthusiastic talks given by Mrs. John Young and the

high School Future Nurses’ Club member who accompa-
nied her from Jamestown. This convention also afforded
the opportunity for a consultation with Mrs. Irene B.
Miller, National League for Nursing field consultant.

As chairman of recruitment, I would like to thank all
those who have helped so much in getting the new pro-
gram underway in North Dakota. Much luck to my suc-
cessor, and I hope she will enjoy it as much as I.

Mrs. E. G. Vinje, Chairman

Historian's Report

The eleventh annual meeting, celebrating the tenth
anniversary of the Woman’s Auxiliary to the North Da-
kota State Medical Association, was held at the Gardner
Hotel, Fargo, May 26, 27, 28, and 29, 1957.

Mrs. C. A. Arneson presided at the preconvention
board and convention meetings. The convention pro-
grams are in the Scrapbook and file. All reports of the
convention are recorded in the October 1957 issue of
The Journal-Lancet.

Thirty-one members responded to roll call on Mon-
day, May 27. This number increased to 76 in attendance
at later meetings. Honored guest speakers were Mrs. Rob-
ert Flanders, Manchester, New Hampshire, national pres-
ident of the Woman’s Auxiliary to the American Medical
Association; Dr. R. H. Waldschmidt, Bismarck, president
of the North Dakota State Medical Association; and Dr.
R. W. Rodgers, Dickinson, president-elect.

The Ten Year History of the Woman’s Auxiliary was
compiled and presented bv the historian. Copies are
filed in archives.

Memorials were given for Mrs. M. W. Garrison, Minot;
Mrs. Frederick O. Gronvold, Fargo; and Mrs. Frank A.
Hill, Grand Forks; and a resolution that “our sincere sym-
pathy be extended to their families” was read by Mrs.
V. J. Fischer, Minot, first vice-president.

Past presidents were honored at the banquet May 27.
An engraved sterling silver compote from the Grand
Forks Medical Auxiliary was presented to Mrs. |. D.
Cardy upon taking office as president after the luncheon
at the Country Club, May 28. Mrs. Callahan, state chair-
man of the National Polio Foundation, presented a Rec-
ognition Award to the state auxiliary. Mrs. C. A. Arneson
accepted.

In response to an invitation from the White House,
Mrs. J. D. Cardy, president, attended the President’s
Conference for Traffic Safety for the midwest region at
the Sherman Hotel, Chicago, April 1.

Mrs. S. C. Bacheller is a board member of the Na-
tional Heart Association. She is area chairman of the
National Auxiliary Committee on Legislation.

State membership numbers 301.

Clara D. Gertson, Historian

Mrs. M. M. Heffron moved that we accept the above
reports. Motion was seconded and carried.

Meeting recessed to reconvene at 2:30 p.m.

A luncheon was served Monday, May 5, at 12:30 p.m.
in the Tree Top Room, Clarence Parker Hotel. Mrs. V. J.
Fischer, state president-elect, presided. She introduced
the convention chairmen, Mrs. Samuel Shea and Mrs.
A. L. Cameron. She then introduced the officers and
honored guest. She presented Dr. O. A. Sedlak, presi-
dent-elect of the North Dakota State Medical Association.
Dr. Sedlak praised us for our many worthwhile projects.
He mentioned the importance of the essay contest in
molding the minds of the children, and he thought this
program should be sponsored. He thought we should
stimulate much more interest in A.M.E.F., as the contri-

OCTOBER 1958

439

butions to A.M.E.F. have been very low in our state.
He told of the introduction of Blue Shield in 1948 and
1949. He stated that this plan was an important factor
in the lives of everyone in the state and nation. He
mentioned some of Dr. Gold’s remarks about what was
happening in Montana. The physicians had lost control
of the Blue Shield plan under lay advisors. He mentioned
that in Canada after the government had taken over
Blue Gross, hospital costs had risen considerably. If the
government subsidizes, it, in turn, dictates how the
money is to be spent. He stressed the importance of
our becoming informed in regard to these prepayment
plans. He gave 2 reasons whv Blue Cross rates had
risen 30 per cent: ( 1 ) increased cost of hospital care and
increased salaries and (2) because doctors hesitate to
make house calls, and send many patients unnecessarily
to the hospital. He expressed concern for the disregard
some physicians have for the patient’s expenses incurred
while in the hospital. He stressed the growing conscious-
ness of “man-made diseases” and emphasized the neces-
sity of staying within the limits of the Blue Cross and
Blue Shield contracts.

A film “For More Tomorrows” was shown by repre-
sentatives of Lederle Laboratories, American Cyanamid
Company, l’earl River, New York.

The convention reconvened at 2:30 p.m. at the Skv
Room of the Clarence Parker Hotel. The meeting was
called to order by Mrs. ]. D. Cardy, president.

Mrs. Cardy told of the honors Dr. L. PI. Landry, Wal-
halla, was receiving — honorary membership in both the
national and state associations. She also mentioned that
he had received his fifty-year pin three years ago. She
then introduced Mrs. Landrv.

The following reports were then read :

American Medical Education Foundation Report

As of April 7, 1958, the sum of $192 has been con-
tributed for the American Medical Education Foundation
in North Dakota. Of this total, $145 has been donated
by 6 of the county auxiliaries and $47 by private con-
tributions. A total of $252 had been contributed by
May 5, 1958.

Donations from any source will be accepted until
May 15, 1958, when all will be tabulated and sent to
the A.M.E.F. executive office in Chicago. We hope that
by that time all auxiliaries will have contributed.

I would like to make 2 suggestions in this report: ( 1)
that the state auxiliary as such make a yearly contribu-
tion to this very important education foundation and (2)
that a committee be appointed to select a card, repre-
sentative of A.M.E.F., to be used by auxiliary members
as a Christmas card. The auxiliary would be responsible
for the design and the cost of printing such a card, ac-
cording to information I have received.

May I take this opportunity to thank the auxiliary
members who have been county charmen for A.M.E.F.
for their cooperation and service during the two years
I have served as state chairman.

Elizabeth Rodgers, Chairman

Motion was made by Mrs. Reichert and seconded by
Mrs. Craven that a committee be appointed to select
a card, representative of A.M.E.F., to be used by auxil-
iary members as a Christmas card, proceeds of which
will go into the A.M.E.F. fund. Motion was carried.

Motion was made by Mrs. Smith and seconded by
Mrs. Longmire that the proceeds from the Christmas
card sales be used as our state contribution rather than
taking an amount from the budget. Motion was carried.

Medical Student Loan Fund Report

Below is a list of how much each district contributed.
First, 68 members (dessert fashion show) $ 200.00

Kotana, 18 members 100.00

Northwest, 59 members 370.00

Devils Lake, 15 members 60.00

Sixth. 59 members (old book sale) 650.00

Southwest, 25 members 50.00

Shevenne

Stutsman, 24 members 125.00

Traill Steele 16.00

Grand Forks, 50 members (rummage sale, dinner dance) 534.46

$2,105.46

During the past year, 13 loans for a total of $6,200
were made. There are 25 loans outstanding for a total
of $11,825.73. Cash on hand amounts to $399.

These figures are as of February 19, 1958.

Mrs. Margaret R. Craven, Chairman

A letter was read from President Starcher suggesting
that we extend our student loan fund to cover freshmen
in medical and even pre-medical school.

Motion was made by Mrs. Van der Linde and sec-
onded by Mrs. Mazur that we leave our student loan
fund as such. Motion was carried.

American Association of Physicians and Surgeons
Essay Contest Report

Mrs. Longmire suggested that every district appoint
an area chairman so that all would be represented in the
state contest. The question arose concerning the money
for the prize winners and whether the bill was to be sub-
mitted to the public relations chairman of the medical
society. YVe discussed whether we should take on the
project as a state activity but still appeal to the associa-
tion for the prizes.

Motion was made by Mrs. Longmire and seconded by
Mrs. Reichert that the auxiliary cooperate with the state
medical society, sponsor of the A.A.P.S. essay contest.
Motion was carried.

Under Revisions, M rs. Cardy stated that we could do
very little until fall when national had completed its
revisions. She stated that councillors should still be
elected at district levels.

Auxiliary President's Report — First District

First District Medical Auxiliary lias 68 members, the
same number as last year.

Three meetings have been held this year. The first
was a dinner meeting at the Gardner Hotel, October 29,

1957. Mrs. Leslie Sachow, local chairman of the Cancer
Society, spoke on the work of the local Cancer Society
and the part our auxiliary can take in its program. The
second meeting, January 29, 1958, was a luncheon meet-
ing at the Frederick-Martin Hotel. Our state president,
Mrs. James Cardy, was our honored guest and speaker.
Mrs. j. J. Stratte, state corresponding secretary, was also
a guest. The third meeting, March 25, 1958, was a din-
ner meeting at the Gardner Hotel. The cancer educa-
tion film, “Horizons of Hope,” was shown. Our fourth
and last meeting will be a luncheon meeting on April 30,

1958. The speaker will talk on civil defense, and elec-
tion of officers will be held.

This year, our district had 5 main projects. Our first
consisted of sponsoring the A.A.P.S. essay contest for
high school students in our district. Mrs. John Bond was
a capable and enthusiastic chairman for our initial par-
ticipation in this national program. Letters, posters, and
bibliographies were sent to the 38 high schools in our
district. Local prizes were offered. While the student
response was disappointing, we felt that it was a start

440

THE JOURNAL-LANCET

on a project of value to the medical association in the
field of public relations. Our district medical society con-
tributed financially toward our expenses and prize money.

Our second project was our cancer education program.
With Mrs. H. A. Norum working as chairman, the pro-
gram chairman of every woman’s organization in all the
churches was asked to plan a program for her group
showing an educational cancer film. Meeting time and
place were recorded and given to the Cancer Society.

Our third project was our annual benefit dessert and
style show, held February 14 at the Elks’ Club. The hard
work and excellent planning of the committee, with Mrs.
L. E. Wold and Mrs. L. C. Pray as co-chairman, were
well worth the effort. Some of our own members mod-
elled. We were thus able to send $200 to the student
loan fund and $75 to A.M.E.F.

For our fourth project, we sponsored a booth on health
careers at the annual high school science fair on March
28 and 29. With the help of St. Luke’s Hospital and St.
John’s Hospital, demonstrations, exhibits, and literature
were given students and parents on careers in x-ray,
medical technology, nursing, and dietetics. Mrs. Lee
Christoferson was chairman.

Our fifth project will be a tea for high school girls
interested in nursing careers and will be followed by
tours of St. John’s and St. Luke’s hospitals.

Our recruitment chairman, Mrs. Calvin Fercho, is
planning the tea for the end of April to tie in with
Career Day at the high school.

Three of these projects were new undertakings this
year and may well be continuing projects.

Upon investigation, we found that the public schools,
fire department, and police department have such a com-
plete and well organized safety program that our en-
deavors in this field would be superfluous.

Plans for Mental Health Week have not been made
as yet.

The fact that we have only 6 subscriptions to Today’s
Health is disappointing.

Individual members have worked on the United Fund
Drive, March of Dimes, Heart Fund, Cancer Society,
Tuberculosis, Christmas Seals, Red Cross, and the Volun-
teer Service Bureau.

First District officers and chairmen, all from Fargo,
are:

Mrs. C. M. Hunter, 1434 S. 6th St.; Mrs. George Thompson,
421 S. 14th St.; Mrs. M. H. Poindexter, 1350 S. 9th St.; Mrs. D.
T. Lindsay, 1505 S. 11th St.; Mrs. John H. Bond, 516 S. 13th
St.; Mrs. H. A. Norum, 1533 S. 6th St.; Mrs. Calvin Fercho,
1502 S. 10th St.; Mrs. G. U. Ivers, 1106 S. 10th St.; Mrs. Robert
J. Ulmer, 1433 S. 12th St.; Mrs. B. C. Corbus, 1257 N. 4th St.;
Mrs. W. E. G. Lancaster, 1332 N. 5th St.; Mrs. L. G. Pray, 1701
S. 8th St.; Mrs. L. E. Wold, 1708 S. 9th St.; and Mrs. Lee
Christoferson, 1307 S. 6th St.

Mrs. B. A. Mazur, President

Auxiliary President's Report — Second District

The auxiliary to the Devils Lake District Medical
Society held 7 meetings this past year 1957 and 1958.
In spite of the fact that members are from widely scat-
tered points, we had a very enjoyable year. Our paid-up
members totaled 15. Our meetings were social and held
at The Ranch in Devils Lake.

Our auxiliary subscribed 100 per cent to the Bulletin
and many members subscribe to Today’s Health. We
donated to the student loan fund. The auxiliary matched
the $25 given by the Devils Lake Association toward
prizes for the essay contest.

Our members have been active in local community
projects, such as Red Cross, park boards, hospital auxili-
aries, P.T.A., Cub Scouts, Brownies and church groups.

Mrs. M. R. Gilchrist, President

Auxiliary President's Report — Third District

The members of the Grand Forks District Medical
Auxiliary are very proud of our state president, Mrs.
James Cardy, a member of our district.

Our auxiliary for the current year has 50 members.
In April, we were saddened by the loss of one of our
members, Mrs. A. F. Panek, of Milton. She will be
greatly missed by all who knew her.

We have had 4 meetings during the year 1957 and
1958. Our first meeting, a luncheon, was held at the
Ryan Hotel, October 17. Since it was our first of the
season, it was a “get acquainted” meeting. New and
prospective members as well as out-of-town members
were introduced. A special effort had been made to
encourage the attendance of out-of-town members. Miss
Carol Braund, soprano soloist, sang during the afternoon.
The second meeting was held at the Dacotah Hotel on
November 20. Dr. Ralph Mahowald gave a most inter-
esting and instructive talk on civil defense. A discussion
period followed. On January 15, the members of the
Medical Students’ Wives Club were our guests at the
Ryan Hotel. We were pleased to have Mrs. James Cardy,
our able state president, as our speaker. She spoke on
the vital parts of our auxiliary program and on current
legislation. It was a very interesting and informative
talk. The medical students’ wives joined us in a question
and answer period after the program. Our last meeting
was held March 16 at the Hotel Dacotah. Annual re-
ports were given, and officers for the coming year were
elected. Guests of honor were Mrs. James Cardy, and
2 members who are leaving soon, Mrs. Robert Turner
and Mrs. Jack Revere.

Each month one of the auxiliary members offers the
use of her home to the Medical Students’ Wives Club
for their meetings. This year the club voted in favor of
joining the Woman’s auxiliary to the Student American
Medical Association. Their affiliation with this national
organization is planned for the coming year. We spon-
sor this group.

A total of $534 was sent to the medical student loan
fund. This sum was obtained from profits of our annual
medical student loan fund dinner dance held at the
new Grand Forks Armory in February, 2 rummage sales
held at the Y.M.C.A. in September and April, and 2
memorial contributions to the fund by the medical
school personnel in memorv of Dr. Walter Wasdahl’s
father who passed away in September and to honor the
memory of his mother-in-law who passed away in March.

The auxiliary sent two $5 memorial contributions to
the A.M.E.F. fund to honor the memory of Dr. H. M.
Waldren, of Drayton, and Mrs. A. F. Panek, of Milton.

As in past years, our members have taken an active
part in community activities. Many of our members are
busy in the St. Michael’s and Deaconess Hospital
auxiliaries and various church groups. Some are active
Red Cross workers, and many participate in the boy and
girl scout programs as well as P.T.A., Y.W.C.A., and
other organizations.

Representatives of the Grand Forks District Medical
Auxiliary served as hostesses and guides when the new
Rehabilitation Center at the University was opened for
public inspection on Saturday afternoon January 25.

Our Today’s Health chairman has reported 27 sub-
scriptions while our Bulletin chairman has reported 9
subscriptions.

The following officers were elected for 1958 and 1959:
Mrs. T. t^). Benson, president; Mrs. Wallace Nelson,
vice-president; Mrs. Nelson A. Youngs, secretary; and
Mrs. Louis B. Silverman, treasurer.

OCTOBER 1958

441

I am grateful to the members of this auxiliary for the
loyal cooperation which has been given to me at all times
during the past year.

Mrs. E. L. Grinnell, President

Auxiliary President's Report — Fourth District

Membership in the Northwest District Auxiliary for
the current year numbers 34 members and 2 honorary
members. The Northwest District uses the “package deal”
of $10 to cover local, state, and national dues and sub-
scriptions to Today’s Health and the Bulletin.

The auxiliary will have had 4 regular meetings, 2
dinners, and 2 luncheons, by the close of the business
year in April. At the April meeting, election of officers
will be held and convention plans discussed.

Our fall meeting was devoted to packaging and dis-
tributing bags for our second “Paper in a Poke” sale for
student loan funds. Over 550 bags were packed and
sold, netting $370. This project keeps everyone busy in
October and November and keeps the auxiliary members
in constant contact with one another.

Mrs. J. D. Cardy, our state president, visited us in
January at a dinner meeting where she urged all mem-
bers to write our congressmen opposing bill IlR-9467.
Mrs. Cardy also instituted in the Northwest District
the practice of giving our pledge in opening meetings.
She also pointed out that each auxiliary should choose
projects which are most workable in a particular dis-
trict and which would be of most interest to them.

Convention plans were formed during our March
meeting. The auxiliary contributed $50 to the A.M.E.F.
this year.

We were late in starting on the essay contest but
found it would have been accepted enthusiastically if the
students had had more time. Therefore, our same chair-
man has consented to take over this new project next
year, and we’re confident much better results will be
achieved.

Members of the auxiliary have served on both the St.
Joseph and Trinity hospital guilds and also assisted in
the annual Shamrock Tea at Trinity Hospital. Many
members have been active as individuals in community
projects, such as Mothers’ March on Polio, Red Cross
drive, and Girl and Roy Scout organizations.. The
auxiliary was asked if our members would start the
polio coffee party drive, and a number did so.

Mrs. O. S. Uthus, President

Fifth District Report

As you know, our group has been inactive during the
past year. For various reasons, so few doctors’ wives
were able to attend meetings that we decided to be-
come inactive until the situation changed. We hope we
can function before too long as we miss the pleasure
of being together.

Mrs. Neil MacDonald has continued in the capacity
of president and I as councillor so that we have kept in
contact with the state organization.

Rest wishes for a successful convention.

Mrs. Gunder Christianson, Councillor

Auxiliary President's Report — Sixth District

The Sixth District Medical Auxiliary has 61 members
this year.

During the year, we have had 3 dinner meetings. Our
first meeting was held in October at the Prince Hotel.
Dr. Alice Peterson, director of Maternal and Child
Health for the State Health Department, spoke to ns.
At our second meeting in December, members sang
Christmas carols and were entertained by vocal solos

and readings. Onr third meeting was held on February
26. We were delighted to have Mrs. Cardy as our
special guest that evening. We will have an election of
officers at our fourth meeting in April.

This year we voted to make raising money for the
student loan fund an individual responsibility. Each
member had the choice of donating a minimum of $10
or raising the money herself. As of April 1 we have
$630 in the fund. A small amount of this was raised by
raffling off the centerpieces at our meetings and by a
small used book sale.

As always, our members have participated in many
civic activities. Many members were hostesses and
guests at a series of polio coffee parties. Mrs. Roy Greg-
ware and Mrs. Robert Tudor acted as hostesses at a
tea given by Mrs. John Davis for the legislators’ wives.
Mrs. John Cartwright worked for the Burleigh Countv
Tuberculosis X-ray Unit. Several members are volunteer
workers at the Bismarck Filter Center. Mrs. Paul John-
son served as chairman of the Heart Fund Drive. We
have also participated in the Red Cross drive and the
March of Dimes. Other members are active in the Bis-
marck and St. Alexius hospital auxiliaries, PTA groups,
church organizations, volunteer election work, civic
music clubs, Boy and Girl Scout work, Community
Players, and Garden Clubs.

A check for $25 was sent to A.M.E.F. We plan to
raise this amount next year.

Thirty-two members subscribe to the Bulletin and 9
members have subscriptions for Today’s Health.

We sponsored the A.A.P.S. essay contest. Mrs. Robert
Kling and Mrs. O. V. Lindelow served as chairmen for
this project.

Sixth District is proud of our 5 state chairmen: Mrs.
Clvde Smith, legislation; Mrs. C. A. Arneson, nominating;
Mrs. M. M. Heffron, press and publicity; Mrs. Edmond
Vinje, recruitment; and Mrs. C. J. Baumgartner, finance.

Sixth District officers, all from Bismarck are:

President, Mrs. Robert Tudor, 714 Ave. C. West; vice-president,
Mrs. R. D. Schoregge, 1420 Ave. E.; secretary, Mrs. J. W.
Cleary, 104 Seminole; and treasurer, Mrs. Phillip Dahl, 1111 S.
Highland Acres.

Chairmen, all from Bismarck with the exception of
Mrs. DeMoully of Flasher are:

A.M.E.F. and’ Bulletin, Mrs. Phillip Dahl, till S. Highland
Acres; civil defense and safety, Mrs. Carl Baumgartner, 615
Washington St.; community health, Mrs. R. W. Henderson, 1028
4th St.; Today's Health, Mrs. C. H. Peters, 805 Griffin; press and
publicity, Mrs. M. M. Heffron, 320 Ave. B. West; dinner arrange-
ments, Mrs. C. R. Montz, 315 Park Ave.; Mrs. H. H. Smeenk.
1107 Ave. A.; and Mrs. R. Berg, 219 Ave. B. West; legislation,
Mrs. C. L. Smith, 622 Raymond; mental health, Mrs. J. T. Cart-
wright, 111 S. Highland Acres; nurse recruitment, Mrs. Norvel
Brink, 212 Ave. F. West; organization and membership, Mrs. R.
D. Schoregge, 1420 Ave. E.; program, Mrs. A. M. Thompson, 610
Ave. A East; public relations, Mrs. Robert Kling, 1414 Hanaford;
and Mrs. O. Lindelow, 831 Crescent Lane; community council,
Mrs. Charles Arneson, 714 N. 2nd St.; councillor, Mrs. O. M.
DeMoully; historian, Mrs. R. Gregware, 1 107 S. Highland Acres;
parliamentarian, Mrs. H. M. Berg, 214 Ave. A West; and student
loan fund, Mrs. Carl Baumgartner, 615 Washington.

The wonderful cooperation of mv officers and chair-
men has made my year as president a very happv one.

Mrs. Robert Tudor, President

Auxiliary President's Report — — Seventh District

The Stutsman County Medical Auxiliary has had an
active, productive year. One of our regular projects is,
and has been for some vears, to provide food and good
useable clothing for a needy family at Christmas. This
year we took care of 2 families: 1 in the countv and 1
in the city.

The Future Nurses’ Club has grown. About 10 of
our members will go into training in the fall of this year.

442

THE JOURNAL-LANCET

We feel we have, under the guidance and leadership
of Mrs. John Young, provided an interesting and edu-
cational program for these people.

As a group, our 24 members have been active in key
positions in Red Cross, first aid. United Fund, and P.T.A.
Mrs. Thomas Pederson was the president for the P.T.A.
World Prayer Day. Mrs. Robert Woodward investigated
and reported on milk sanitation in our community when
it was called to our attention that some questions had
arisen on the subject. We learned that we had a Grade
A milk shed. Mrs. Young displayed some of her work
in the art exhibits in Bismarck and Grand Forks. We
have been hostesses at a birthday party for the patients
at the State Hospital and plan to take an active part in
the Cancer Caravan when the time arises.

If we knew the total number of entrants, we might
not be quite so smug, but not knowing allows us to
crow a bit when we state that one of our Jamestown
youngsters, Carol Mergler, placed first in the county
in the essay contest and also won first place in the state.

Our total contribution to the A.M.E.F. is a low $10,
but we have given a total of $125 to the student loan
fund. Since Today’s Health and Bulletin chairman is
out of town, I have no accurate report on subscriptions.

We were fortunate enough to have Nan Cardy, our
state president, as our honored guest at our Christmas
party. Our interest in legislation, student loan fund,
and A.M.E.F. has been greatly increased by her inter-
esting and informative speech on these subjects.

We have had 2 dinner meetings so far this year. Our
final meeting will be held on April 11, at which time
our officers for 1958 and 1959 will be elected.

Mrs. John M. Van der Linde, President

Auxiliary President's Report — Eighth District

The Kotana Medical Auxiliary met on November 15,
1957, with the president Mrs. Gordon Ellis, presiding.
The officers for the year were: president, Mrs. Gordon
Ellis; vice-president, Mrs. Joe Craven; and secretary-
treasurer, Mrs. John Keller.

Election of officers was held. The new officers are as
follows: president, Mrs. John Keller; vice-president, Mrs.
Andrew Sathe; and secretary-treasurer, Mrs. Chester
Borrud.

Chairmen are: Today’s Health, Mrs. Willard Wright;
public relations, Mrs. Dean Strinden; program, Mrs. H.
Charles Walker; civilian defense, Mrs. Justin Korwin;
membership, Mrs. Donald Skjei; legislation, Mrs. Duane
Pile; and councillor, Mrs. John Craven.

Dues were paid for the total membership of 18
members.

The Kotana Medical Auxiliary met at the Williston
Clinic on December 22, 1957 for a dinner meeting.
It was decided at that time to meet 4 times a year in
the future. Total subscriptions for Today’s Health are
22. The amount sent to the A.M.E.F. was $10. The
amount sent to the student loan fund was $100.

The Kotana Medical Society and the Kotana Medical
Auxiliary met at the Elks’ Club on March 24, 1958, for
dinner. Dr. and Mrs. Cardy were our guests. After
dinner, the auxiliary members adjourned to the home
of Mrs. Joe Craven for a business meeting. Our guest
speaker for the evening was Mrs. Cardy, who enlightened
us on many aspects of the auxiliary as a unit.

Mrs. John M. Keller, President

Auxiliary President's Report — Traill-Steele District

As in past years, the Traill-Steele Medical Auxiliary
has found it difficult to organize programs due to the
distances between members. We have 8 members living

in 5 different towns. Therefore, we feel it is much
better to coordinate our activities with those of our
communities, and each member of our district is active
in the civic affairs of her town. These activities include
civil defense, cancer drives, safety programs, mental
health, and so on.

Our meetings are held 4 times a year and are of a
purely social nature. We contribute a small donation
to the student loan fund, and, although we are an in-
active group, we are definitely interested in the work of
the State Medical Auxiliary.

Mrs. R. W. McLean, President

Auxiliary President's Report — Tenth District

The Woman’s Auxiliary to the Southwestern District
Medical Association held 5 dinner meetings during the
year of 1957 and 1958.

The first meeting was held at the home of Mrs. C. R.
Dukart, at which time a report was made on the state
convention by our delegate, Mrs. Lawrence H. Reichert.

At our October meeting, a motion was made and
carried that the subscription price of Today’s Health
be deducted from the dues of each member. Our secre-
tary-treasurer, Mrs. Richard F. Raasch, was instructed to
send a check to the local Today’s Health chairman, Mrs.
Keith G. Foster, who forwarded it to the Chicago
office.

Coffee and cookies donated by the auxiliary were
served by a committee consisting of Mrs. Hans E.
Guloien, Mrs. Lawrence H. Reichert and Mrs. C. R.
Dukart to the North Dakota Crippled Children’s Clinic,
which was held here in September. This was done
through the efforts of Mrs. Robert F. Gilliland, who was
a director for the Crippled Children’s Society.

A holiday dinner was given by Mrs. Richard F.
Raasch at her home for the auxiliary members in Decem-
ber, after which a business meeting was held. Mrs.
Donald J. Reichert, president, in the absence of Mrs.
Arnold J. Gumper, our public relations chairman, dis-
tributed A.A.P.S. essay contest packets to out-of-town
members: Mrs. Walter Knickerbocker of Hettinger, Mrs.
Robert Thom of Bowman, Mrs. A. A. Curiskis of Elgin,
Mrs. Walter Hannewald of Richardton, and Mrs. Robert
E. Hankins of Mott. Mrs. Gumper had previously given
packets to Central High School of Dickinson. Efforts
were made to promote participation in the contest, and
at our February meeting, the judges were selected. Miss
Jane Looney of Dickinson’s Central High School was
our winner and has been awarded a prize of $25, which
was donated by the Southwestern District Medical
Society. The essay was forwarded by Mrs. Gumper to
the state public relations chairman, Mrs. L. T. Longmire.
We hope with the experience gained this year, we will
be able to sponsor a larger group of contestants next year.

In December, Mrs. Richard F. Raasch reported for
Mrs. Amos R. Gilsdorf, who had been working with the
Future Nurses’ Club and with Sister Margaret of St.
Joseph’s Hospital in Dickinson, that Sister Margaret was
interested in having the auxiliary sponsor the newly
formed Future Nurses’ Club of Dickinson. A committee
was appointed consisting of Mrs. Amos Gilsdorf, Mrs.
Ralph Dukart, and Mrs. Keith G. Foster to discuss details
with Sister Margaret. Mrs. Gilsdorf reported at our
February meeting, which was held at the home of Mrs.
Donald J. Reichert, on what would be expected of us
if we sponsored the Future Nurses’ Club. A motion
was then made and carried that we do so. At the March
meeting, Mrs. Gil sdorf reported that the Future Nurses’
Club would have a discussion panel on television station
KDIX, Dickinson, on March 24 at 6:30 p.m. The panel

OCTOBER 1958

443

consisted of Miss JoLin Rodgers, a registered nurse, and
daughter of Dr. and Mrs. R. W. Rodgers; Mr. J. A.
O’Brien, moderator; and 3 members of the Future
Nurses’ Club. The club is now taking a Red Cross first-
aid course and making plans to affiliate with the national
Future Nurses’ Club. They will receive their pins at a
tea which is to be given in May at the home of Mrs.
Donald Reichert. Much credit is due Mrs. Amos Gils-
dorf for the hours she has spent with this group and
also for assisting Sister Margaret at St. Joseph’s Hospital.

It was suggested by Mrs. Lawrence Reichert that we
help develop a coffee service at the hospital for visitors.
Several sponsors are to be contacted about the possibility
of purchasing a coffee machine. We hope to do some-
thing in turn for each hospital in our district.

We have 25 members in the Southwestern District
Medical Auxiliary for 1957 and 1958. Letters were
written bv Mrs. Donald ). Reichert to 2 eligible women,
asking them to join the auxiliary. A reply from one
stated that if her husband remains in our district, she
will join.

In March, a dinner was given at the home of Mrs.
Arnold J. Gumper with Mrs. R. W. Rodgers as co-
hostess, after which a meeting was held. Officers for
1958 and 1959 were elected as follows: Mrs. Richard F.
Raasch, president; Mrs. Donald j. Reichert, vice-presi-
dent; Mrs. R. W. Rodgers, secretary-treasurer; Mrs.
Robert E. Hankins, delegate to the state convention; and
Mrs. R. W. Rodgers, alternate delegate. Mrs. Lawrence
II. Reichert is councillor for the auxilliary. Mrs. Robert
Hankins is editor for News, Views and Cues and North
Dakota Newsletter, and Mrs. Robert F. Gilliland is
state second vice-president.

A financial report made by Mrs. Richard F. Raasch,
secretary-treasurer, in March listed dues paid to:

National and state associations $100.00

American Medical Education Fund 25.00

Student Loan Fund 50.00

Today’s Health, 25 subscriptions 37.50

At this time it was agreed that we keep a larger bal-
ance in the treasury for expenses or projects which
might develop before dues are again collected. Fifteen
dollars was also given A.M.E.F. for sympathy cards.

Mrs. Donald j. Reichert, President

Resolution Report

I.

Be it resolved: That this convention of the Woman’s
Auxiliary to the North Dakota State Medical Association
extend to Mrs. J. D. Cardv its thanks and sincere appre-
ciation for the great service which she has rendered to
that group.

II.

Be it resolved: That the Woman’s Auxiliary to the
North Dakota State Medical Association express grate-
ful appreciation and thanks to the Citv of Minot; to the
Med ical Society of Northwest District; to the auxiliary
convention chairmen; to managers and staffs of the
hotels; to members of the press, radio, and television;
to Mr. Lyle Limond, executive secretary of the North
Dakota State Medical Association, and his staff; to Dr.
R. W. Rodgers, past president; to Mrs. M. A. Gold,
Butte, Montana, national fourth vice-president of the
Woman’s Auxiliary to the American Medical Association;
and to all other groups who have contributed to the1
success of the convention and to the comfort and enter-
tainment of the delegates.

III.

Be il resolved: That the Woman’s Auxiliary to the North
Dakota State Medical Association express appreciation

for the support and cooperation received from all per-
sons, organizations, and agencies who contributed to the
success of its program and that of its state and district
auxiliaries during the past year.

M rs. J. H. Mahoney, Chairman

Motion was made by Mrs. Fischer and carried that we
adopt the resolution.

Under election of delegates to the A.M.A., June 23 to
27, San Francisco, the president was given power to
appoint delegates.

Nominating Committee Report — 1958-1959

President, Mrs. V. j. Fischer, Minot; president-elect,
Mrs. John Van der Linde, Jamestown; first vice-president,
Mrs. Robert F. Gilliland, Dickinson; second vice-presi-
dent, Mrs. R. W. McLean, Hillsboro; recording-secretary,
Mrs. John Jansonius, Jamestown; treasurer, Mrs. Carl J.
Baumgartner, Bismarck.

Mrs. Charles A. Ahneson, Chairman
Mrs. Swanson
Mrs. Soreness
Mrs. Gammel

Mrs. Cardy then asked for nominations from the floor.
As there were none, she declared the above persons duly
elected and instructed the secretary to so record this in
the minutes.

Mrs. R. McLean then read the following prosposed
budget for 1958 and 1959.

Proposed Budget — 1958 - 1959

Proposed expenditures:
President:

National convention
Chicago conference
Discretionary' fund
Miscellaneous fund

$ 265.00
117.50
100.00
25.00

President elect:

S 507.50

Chicago conference

117.50

Standing and special committees

60.00

News, Views and Cues

175.00

Stationery

22.00

Convention expenses

260.00

File cabinet

75.00

Miscellaneous

40.00

749.50

$1,257.00

Mrs. C. T. Baumgartner
Mrs. R. W. McLean
Mrs. Reuben Waldschmidt
Mrs. H. L. Kermott, Jr.

Mrs. Ernest Larson

Mrs. R. W. Rodgers moved that we accept the pro-
posed budget as read.

Meeting adjourned.

A delightful banquet was held Monday, Max 5 at
6:30 p.m. in the Sliver Saddle Room of the Clarence
Parker Hotel, with Mrs. Oliver Uthus, Northwest Dis-
trict president, presiding. Mrs. Uthus introduced the
convention chairmen, Mrs. Shea and Mrs. Cameron, and
the honored guest and speaker, Mrs. M. A. Gold, of
Butte, Montana, fourth \ ice-president of the Woman’s
Auxiliary to the American Medical Association. Mrs.
Gold stressed the importance of our appointing chair-
men to work closely with the doctors who hold parallel
positions and especially someone to work with a kev man
on the same legislative program. She advised us to
publicize our scholarships and loans in the recruitment
of nurses and allied positions. She gave the 3-point
action program for traffic safety to be carried out at the
communitv lexcl. Recommendations made In the A.M.A.

444

THE JOURNAL-LANCET

committee were: ( 1 ) a driver training course in every
high school, ( 2 ) shop for safety when you buy a car,
and (3) work toward legislation to keep the drinking
driver off the highway. She quoted from Dr. Allman on
the concrete results of our labor in the auxiliary. She
said, “Don’t tell us how good we are; just tell us what
to do.” She stated that since there were 2 'A million more
women than men in the United States, we had the
balance of power in our hands and how we used it was
up to us. She mentioned the force in this country that
was greater than the atomic bomb — public sentiment.
She stated that if we started to talk about the same
thing at the same time, we could form public opinion
that political parties could not ignore or overlook. She
([noted statistics in regard to our time-saving devices.
She said that formerly it took five and one-half hours to
prepare a meal for a family of 4; it now takes one hour
and thirty-five minutes, a gain of three hours a day.
She said that we not only had the natural ability to
mold public opinion but that we had the time and
advised us to use our influence.

Our last session was held Tuesday, May 6, at 11:00
a.m. at the Riverside Lodge. Mrs. Samuel Shea, con-
vention chairman, presided. A lovely brunch was served.
Prizes were awarded and a gift was presented to Mrs.
Gold. Mrs. Gold installed the new officers, Mrs. Ralph
Wallin was our vocalist. Mrs. |. D. Candy then presented
the gavel to the new president, Mrs. V. J. Fischer.

Postconvention Minutes

Mrs. V. J. Fischer called the meeting to order. She
asked that the members of the medical society with
positions comparable to ours be contacted for guidance
and suggestions as to what could be accomplished. She
asked that the treasurer’s books be closed in June and
audited at the fall board meeting. She announced that
Mrs. Waldschmidt was our new finance chairman.

Mrs. J. D. Cardy stressed the point that the nomi-
nating committee should function as 4 people. The
following were elected to serve on the nominating com-
mittee with Mrs. ]. D. Cardy: Mrs. Joel Swanson, Mrs.
|oseph Sorkness, and Mrs. R. T. Gammell. Mrs. Cardy
suggested that the nominating committee should plan a
meeting.

Motion was made by Mrs. Cardy and seconded by
Mrs. Longmire that the new member of the five-member
revolving finance committee be appointed by the presi-
dent. Motion carried. It was decided the fifth member
of the Student Loan Committee should be appointed
by the president also. Mrs. V. J. Fischer asked that all
reports be sent in triplicate: 1 to the president, 1 to the
secretary, and 1 for the files.

It was suggested that the following names be sub-
mitted to Sally Wold, A.M.E.F. chairman, for help in
designing the A.M.E.F. Christmas card: Mrs. Marlin

Johnson, Mrs. Buckingham, Mrs. Pierce, and Mrs. John
Young.

XUs. Halliday asked that we attempt to establish a
Student Nurses’ Scholarship. Motion was made by Mrs.
Kermott and seconded bv Mrs. Van der Linde that our
recruitment chairman, Mrs. Young, study and investigate
existing scholarships and present this at our fall board
meeting. Motion carried.

It was decided that delegates to the A.M. A. be
selected from those who planned to attend. Those chosen
were Mrs. T. E. Pederson and Mrs. J. W. Jansonius.

After discussion, the group felt that the essay contest
plans should be left to the decision of Mrs. Longmire.
Meeting adjourned.

1 he following is a list of officers, directors, and chair-
men of standing and special committees of the Woman’s
Auxiliary to the North Dakota State Medical Association
for 1958 and 1959.

State OHicers

President — Mrs. V. J. Fischer, 303 8th Ave. S.E., Minot
President-elect — Mrs. J. M. Van der Linde,

209 N.E. 3rd St., Jamestown
First vice-president — Airs. R. F. Gilliland,

228 9th St. W., Dickinson

Second vice-president — Mrs. R. W. McLean, Hillsboro
Recording secretary — Mrs. J. W. Jansonius,

609 4th Ave. S.E., Jamestown
Corresponding secretary — Mrs. Darwin Kohl,

209 8th Ave. S.E. Minot
Treasurer — Mrs. Carl Baumgartner,

615 N. Washington, Bismarck

State Committee Chairmen

Organization — Mrs. J. M. Van der Linde,

209 N.E. 3rd St., Jamestown
Program — Mrs. R. F. Gilliland,

228 9th St. W., Dickinson
Civil defense — Mrs. Ralph D. Weible,

1628 9th St. S., Fargo

Nominating — Mrs. |. D. Cardy,

1110 Reeves Drive, Grand Forks
Press and publicity — Mrs. M. M. Heffron

(manager and chairman), 320 Ave. B W., Bismarck;
Mrs. Robert Hankins (editor), Mott; and Mrs. C.
A. Arneson, 714 N. 2nd St., Bismarck
Public relations-»-Mrs. R. W. McLean

(chairman), Hillsboro; and Mrs. L. 4'. Longmire,
810 6th St., Devils Lake
Legislation — Mrs. Clyde Smith,

622 Raymond St., Bismarck
Bulletin — Mrs. Andrew G. Sathe,

718 15th St. W„ Williston
Historian — Mrs. G. D. Gertson,

51 1 S. 5th St., Grand Forks
A.M.E.F. — Mrs. Lester Wold,

1708 S. 9th St., Fargo
Parliamentarian — Mrs. E. L. Grinnell,

1207 Lincoln Drive, Grand Forks
Mental health — Mrs. S. E. Shea,

808 1st St. S.E., Minot

Recruitment — Mrs. John Young,

505 3rd Ave. S.E., Jamestown
Rural health — Mrs. William Fox, Rugby
Revisions — Mrs. Henry Kermott, |r.,

200 7th Ave. S.E., Minot

Safety — Mrs. L. L. Hoopes,

118 9th Ave. S.E., Minot
Todai/’s Health — Mrs. Neville Turner, La Moure
Resolutions — Mrs. L. T. Longmire,

810 6th St., Devils Lake
Finance committee — Mrs. R. II. Waldschmidt (chairman),
600 N. Washington, Bismarck; Mrs. E. J. Larson,
321 2nd Ave. S.E., Jamestown; Mrs. L. H. Kermott,
200 7th Ave. S.E., Minot; Mrs. Carl Baumgartner,
615 N. Washington, Bismarck; and Mrs. W. L.
Macaulay, 1410 S. 9th St., Fargo
Medical student loan fund — Mrs. B. A. Mazur (chairman),
1237 N. 3rd St., Fargo; Mrs. R. H. Waldschmidt,
600 N. Washington St., Bismarck; Mrs. J. A. Sand-
meyer, 1005 Lanark, Grand Forks; Mrs. Gale R.
Richardson, 12 10th St. S.W., Minot; and Mrs.
John M. Keller, 910 4th Ave. E., Williston.

OCTOBER 1958

445

District Presidents

First District — Mrs. B. A. Mazur, 1237 N. 3rd St., Fargo
Second District — Mrs. |. Terlecki, Minnewaukan
Third District — Mrs. T. Q. Benson, 1524 Walnut, Grand
Forks

Fourth District — Mrs. William Kitto, 1021 Central Ave.
W., Minot

Fifth District — No Auxiliary

Sixth District — Mrs. R. D. Schoregge, 1420 Ave. E.,
Bismarck

Seventh District — Mrs. |. M. Miles, Jamestown
Eighth District — Mrs. j. M. Keller, 910 4th Ave. E.
Williston

Traill-Steele — Mrs. R. W. McLean, Hillsboro
Tenth District — Mrs. R. F. Raasch, 30 W. 8th St., Dick-
inson

WOMAN'S AUXILIARY TO THE NORTH DAKOTA STATE MEDICAL ASSOCIATION

1957 MEMBERSHIP ROSTER

Devils Lake District

N indicates new member; W indicates widow

Cook, Mrs. Suart J. (N)
Corbett, Mrs. C. A.

Fawcett, Mrs. John C.
Fawcett, Mrs. Robert M.

Fox, Mrs. William R

Gilchrist, Mrs. Milton R.
Lazareck, Mrs. Isadore L.
Longmire, Mrs. L. T.
McBane, Mrs. Robert D.
Mahoney, Mrs. James H.
Munro, Mrs. Jerrold A. (N)
Palmer, Mrs. Dolson W.
Pine, Mrs. Louis F.

Terlecki, Mrs. Jaroslaw

Rolette

316 7th St., Devils Lake
1 125 5th St., Devils Lake
719 4th St., Devils Lake
Rugby
Rolla

1032 5th St., Devils Lake
810 6th St., Devils Lake
Towner

601 8th St., Devils Lake
Rolla
Cando

817 7th St., Devils Lake
Minnewaukan

First

Amidon, Mrs. B. F.
Armstrong, Mrs. W. B.
Bacheller, Mrs. S. C.
Barnard, Mrs. Donald
Behling, Mrs. F. L.

Beithon, Mrs. E. J.

Bond, Mrs. J. H. (W)

Borland, Mrs. V. G

Burton, Mrs. P. H. (W)
Christoferson, Mrs. Lee
Christu, Mrs. Chris N. (N)
1417 S. 5th
Corbus, Mrs. B. C.

Darrow, Mrs. K. E.
DeCesare, Mrs. F. A.

Donat, Mrs. T. L.

Engstrom, Mrs. P. H. (N)
Fercho, Mrs. Calvin
Fjelde, Mrs. J. H. (W)
Fortin, Mrs. H. J. (W)
Fortney, Mrs. A. C.

Geib, Mrs. Marvin
Gillam, Mrs. J. S.

Goff, Mrs. John R.

Goltz, Mrs. Neill F.
Gustafson, Mrs. Maynard
Hall, Mrs. G. H.

Hanna, Mrs. J. F. ( W )
Hawn, Mrs. Hugh W.
Heilman, Mrs. Charles
Houghton, Mrs. |. F.
Hunter, Mrs. C. M.

Irvine, Mrs. V. S.

Ivers, Mrs. G. U.

District

1325 S. 6th Ave., Fargo
1710 S. 8th St., Fargo
Enderlin
1111 S. 7th St„ Fargo
1414 S. 10th St., Fargo
Wahpeton
516 S. 13th St., Fargo
1514 S. 9th St., Fargo
415 S. 8th St„ Fargo
1307 S. 6th St., Fargo

Ave., Moorhead, Minnesota
1257 N. 4th St., Fargo
716 S. 8th St., Fargo
1401 S. 9th St., Fargo
1109 S. 9th St., Fargo
Wahpeton
1502 S. 10th St„ Fargo
1526 S. 8th St., Fargo

1440 S. 8th St., Fargo
1505 S. 12th St., Fargo

Moorhead, Minnesota

1433 7th St. S., Fargo

1441 S. 8th St., Fargo
802 S. 8th St., Fargo
1410 S. 5th St., Fargo

1748 S. 9th St., Fargo
907 S. 12th Ave., Fargo
1325 N. 1st St., Fargo
49 N. 18th Ave., Fargo
1707 S. 9th St., Fargo

1434 S. 6th St., Fargo

Lidgerwood
1106 S. 10th St., Fargo

Jaehning, Mrs. David
James, Mrs. J. B. (W)
Klein, Mrs. A. L.

Lancaster, Mrs. W. E. G.
Lauda, Mrs. Marshall
Larson, Mrs. G. A.

LeBien, Mrs. Wayne

Lewis, Mrs. T. H.

LeMar, Mrs. John D.
Lindsay, Mrs. D. T.

Long, Mrs. W. H.

Lytle, Mrs. F. T

Macaulay, Mrs. W. L.
Mazur, Mrs. B. A.

Melton, Mrs. F. M.

Murray, Mrs. James B. (N)
Nichols, Mrs. A. A. (W)
Norum, Mrs. H. A.
Poindexter, Mrs. M. H.
Pray, Mrs. L. G.

Rogers, Mrs. R. G.
Sehleinitz, Mrs. Fritz B.
Sedlak, Mrs. O. A.

Shook, Mrs. Lester D.
Stafne, Mrs. W. A.

Story, Mrs. Robert
Swanson, Mrs. |. C.
Thompson, Mrs. George
Triggs, Mrs. Perry O.
Ulmer, Mrs. Robert J. (N)
Webster, Mrs. W. O.
Weible, Mrs. R. D.

Weible, Mrs. R. E. (W)
Wold, Mrs. L. E.

Zauner, Mrs. R. |.

Wahpeton
1145 N. 10th St., Fargo
1441 S. 9th St., Fargo
1332 N. 5th St., Fargo
1335 S. 6th St., Fargo
1538 S. 9th St., Fargo
1353 N. 5th St., Fargo
1502 S. 6th St., Fargo
1324 N. 5th St., Fargo
1505 S. 11th St., Fargo
1438 S. 8th St., Fargo
Moorhead, Minnesota
1410 S. 9th St., Fargo
1237 N. 3rd St., Fargo
1545 S. 6th St., Fargo
1206 S. 15 X Ave., Fargo
358 S. 6th St., Fargo
1533 S. 6th St., Fargo
1350 S. 9th St., Fargo
1701 S. 8th St., Fargo
1217 S. 7th St., Fargo
Hankinson
1019 S. 9th St., Fargo
1755 S. 10th St., Fargo
1409 S. 9th St., Fargo
1315 S. 9th St., Fargo
1220 S. 8th St., Fargo

421 S. 14th St., Fargo

1401 S. 12th St., Fargo
. 1433 S. 12th St., Fargo

823 S. 14th St., Fargo

1628 S. 9th St., Fargo
1630 S. 9th St„ Fargo
1708 S. 9th St., Fargo
1005 N. 13th Ave., Fargo

Grand Forks District

Andrews, Mrs. Phillip (N) 2308 7tb Ave. N., Grand Forks
Arneson, Mrs. A. O. (W) 419K S. 5th St., Grand Forks

Bakewell, Mrs. William (N)

517 Reeves Drive, Grand Forks
Benson, Mrs. Theodore 1524 Walnut St., Grand Forks
Benwell, Mrs. Harry D. 625 S. 3rd St., Grand Forks
Berger, Mrs. P. R. 2216 10th Ave. N„ Grand Forks
Cardy, Mrs. James D. 1110 Reeves Drive, Grand Forks
Clavburgh, Mrs. B. }. 729 Reeves Drive, Grand Forks

Countryman, Mrs. George L. Grafton

Culmer, Mrs. A. E., Jr. 101 Reeves Court, Grand Forks
Dailey, Mrs. Walter C. 1812 Belmont Rd., Grand Forks
Delano, Mrs. Robert Northwood

Fritzell, Mrs. Kenneth F. (W)

1125 Reeves Drive, Grand Forks

446

THE JOURNAL-LANCET

Gertson, Mrs. G. D. (W) 511 S. 5th St., Grand Forks

Goehl, Mrs. R. O. 1015 Reeves Drive, Grand Forks
Graham, Mrs. Charles M.

925 Almonte Ave., Grand Forks
Graham, Mrs. John H. 1523 Cottonwood, Frand Forks
Grinnell, Mrs. E. L. 1207 Lincoln Drive, Grand Forks
Harwood, Mrs. T. H. Belmont Rd., Grand Forks

Haugen, Mrs. C. O. Larimore

Haunz, Mrs. Edgar A. 1029 Lincoln Drive, Grand Forks
Jensen, Mrs. A. F. 1712 Belmont, Grand Forks

Keig, Mrs. William P. ( N ) 602 Cherry St., Grand Forks
Leigh, Mrs. James A.

606 N. 3rd St., East Grand Forks, Minnesota
Leigh, Mrs. Ralph E. 301 Park Ave., Grand Forks

Leigh, Mrs. Richard ( N )

1117 Lincoln Drive, Grand Forks
Liebeler, Mrs. W. A. (W)

504*2 Reeves Drive, Grand Forks
McLeod, Mrs. John J. 911 N. 22nd St., Grand Forks
Mahowald, Mrs. Ralph E. 606 S. 5th St., Grand Forks
Moore, Mrs. John H. 1114 Reeves Drive, Grand Forks
Mims, Mrs. O. Harold 59 4th Ave. S., Grand Forks
Nelson, Mrs. Wallace W. 511 17th Ave. S., Grand Forks
Painter, Mrs. R. C. 1121 Belmont Rd., Grand Forks

Pettit, Mrs. Sam 625 Reeves Drive, Grand Forks

Porter, Mrs. Charles B. 1210 Chestnut St., Grand Forks
Potter, Mrs. W. F. 2024 2nd Ave. N., Grand Forks
Powers, Mrs. William 1509 Walnut, Grand Forks

Prochaska, Mrs. L. J. 620 Reeves Drive, Grand Forks

Revere, Mrs. J. W. 821 Letnes Drive, Grand Forks

Ruud, Mrs. John E. 2001 Chestnut St., Grand Forks
Sandmeyer, Mrs. John A. 1005 Lanark Ave. Grand Forks
Silverman, Mrs. Louis B. 626 Belmont Rd., Grand Forks
Stratte, Mrs. J. J. (W) 403 Division Ave., Grand Forks

Strom, Mrs. A. D. 2201 7th Ave. N., Grand Forks

Thorgrimsen, Mrs. G. G. 1615 4th Ave. N,. Grand Forks
Turner, Mrs. Robert O. 1120 Cottonwood, Grand Forks
Waldron, Mrs. George (W) 403 Division, Grand Forks

Witherstine, Mrs. W. H. 214 8th Ave. S., Grand Forks
Woutat, Mrs. Phillip H.

1205 Lincoln Drive, Grand Forks
Youngs, Mrs. Nelson A. 511 Reeves Drive, Grand Forks

Kotana District

Borrud, Mrs. Chester C. 729 16th St. W., Williston

Craven, Mrs. John P. 403 3rd Ave. E., Williston

Craven, Mrs. Joseph D. 915 2nd Ave. E., Williston

Ellis, Mrs. Gordon E. 602 14th Ave. W., Williston
Fennell, Mrs. W. Loren Crosby Clinic, Crosby

Hagan, Mrs. Edward J. 904 2nd Ave. E., Williston

Hagan, Mrs. Joan G. (W) 410 2nd Ave. E., Williston

Johnson, Mrs. Alan K. 1004 4th Ave. E., Williston

Keller, Mrs. John M. 910 4th Ave. E., Williston

Korwin, Mrs. Justin J. 701 2nd Ave. E., Williston

Lund, Mrs. Carroll M. 701 1st Ave. E., Williston

McPhail, Mrs. Clayton O. Crosby Clinic, Crosby

Pile, Mrs. Duane F. Crosby Clinic, Crosby

Sathe, Mrs. Andrew G. 718 15th St. W„ Williston

Skjei, Mrs. Donald E. 803 1st Ave. W., Williston

Strinden, Mrs. Dean R. 1717 8th Ave. W., Williston

Walker, Mrs. H. Charles 1709 Hillside Court, Williston
Wright, Mrs. Willard A. 822 2nd Ave. E„ Williston

Northwest District

Amstutz, Mrs. Kenneth N. 505 9th Ave. S.E., Minot
Breslich, Mrs. Paul J. 818 4th St. S.E., Minot

Cameron, Mrs. Angus L. 318 8th Ave. S.E., Minot
Clark, Mrs. Joseph H. 625 5th St. S.E., Minot

Devine, Mrs. John L. 7 Airview, Minot

Erenfeld, Mrs. Fred R. 616 Lincoln Ave., Minot

Fischer, Mrs. Verrill J.
Gammell, Mrs. Robert T.
Giltner, Mrs. Llovd A.
Goodman, Mrs. Robert
Halliday, Mrs. David ).
Halverson, Mrs. C. H.

Hart, Mrs. George M.
Hoopes, Mrs. Lorman L.
Hordinsky, Mrs. Bohdan Z.
Huntley, Mrs. Wellington B.
Hurly, Mrs. William C.
Kermott, Mrs. Henry L., |r
Kitto, Mrs. William
Kohl, Mrs. Darwin L.
Lampert, Mrs. Max T.
London, Mrs. Carl B.
McCannel, Mrs. A. D.
McCardle, Mrs. John S.
McDougall, Mrs. James B.
Naegeli, Mrs. Frank D.
Olson, Mrs. Burton
Richardson, Mrs. Gale R.
Seiftert, Mrs. G. S.

Shea, Mrs. Samuel E.
Sorenson, Mrs. Alfred R.
Sorenson, Mrs. Roger
Uthus, Mrs. Oliver
Vaaler, Mrs. Raymond A.

308 8th Ave. S.E., Minot
Kenmare

1000 4th Ave. N.W., Minot
Powers Lake
Kenmare

322 8th Ave. S.E., Minot

213 7th Ave. S.E., Minot

118 9th Ave. S.E., Minot
Drake-

208 7th Ave. S.E., Minot

69 9th St. S.E., Minot

. 200 7th Ave. S.E., Minot

1021 Central Ave. W., Minot

209 8th Ave. S.E., Minot

101 10th St. N.W., Minot

506 Main St. S., Minot

505 Main St. S.,
222 Souris Drive,
908 3rd St., S.E.,

Minot

Minot

Minot

920 3rd St. N.W., Minot

629 3rd St. S.E., Minot
12 10th St. S.W., Minot
Rural Minot
808 1st St.S.E., Minot
114 6th St. S.E., Minot
101 9th St. S.E., Minot
916 Central Ave. W., Minot
1711 6th St. S.W., Minot

Sixth District

Anderson, Mrs. F. E. Underwood

Arneson, Mrs. Charles 714 N. 2nd St., Bismarck

Baumgartner, Mrs. C. [. 615 N. Washington, Bismarck

Berg, Mrs. H. Milton 214 Ave. A West, Bismarck

Berg, Mrs. Roger M. 219 Ave. B West, Bismarck

Bertheau, Mrs. H. |. Linton

Boerth, Mrs. Edwin II. (W) 825 Griffin, Bismarck

Boyle, Mrs. John Garrison

Brink, Mrs. Norval O. 212 Ave. F West, Bismarck
Buckingham, Mrs. Tracy W. 1030 5th St., Bismarck
Cartwright, Mrs. John T.

1110 S. Highland Acres, Bismarck
Cleary, Mrs. Joseph W. 104 Seminole, Bismarck

Dahl, Mrs. Phillip O. 1111 S. Highland Acres, Bismarck
DeMoully, Mrs. Oliver ( W ) Flasher

Diven, Mrs. Wilbur 119 Ave. B West, Bismarck

Eriksen, Mrs. |ohan A. 815 Ave. C West, Bismarck

Freise, Mrs. P. W 831 Mandan St., Bismarck

Gaebe, Mrs. O. C. New Salem

Girard, Mrs. B. A. Beulah

Goughnour, Mrs. Myron 1310 N. 2nd St., Bismarck
Gregware, Mrs. P. Roy 1107 S. Highland Acres, Bismarck
Heffron, Mrs. M. M. 320 Ave. B West, Bismarck

Henderson, Mrs. R. W 1028 4th St., Bismarck

Hetzler, Mrs. A. E. 602 6th Ave. N.W., Bismarck

Icenogle, Mrs. Grover 608 W. Thayer, Bismarck

Jacobson, Mrs. Melvin Elgin

Johnson, Mrs. Kenneth 211 Cheyenne Ave., Bismarck
Johnson, Mrs. Marlin J. E.

1020 N. Washington St., Bismarck
Johnson, Mrs. Paul L. 224 Ave. A West, Bismarck
Kalnins, Mrs. Arnold Washburn

Kling, Mrs. Robert R. 1414 Hannaford, Bismarck

Kuplis, Mrs. Haralds Turtle Lake

Larson, Mrs. L. W. 700 Tower, Bismarck

Lindelow, Mrs. O. Victor 831 Crescent Ave., Bismarck
Lipp, Mrs. George R. 502 W. Rosser Ave., Bismarck
Lommen, Mrs. M. A. K. 304 Ave. B East, Bismarck
McGee, Mrs. William J. (N)

104 Missouri Drive, Riverdale

OCTOBER 1958

447

Montz, Mrs. C. R. .315 E. Park Ave.,

Nuessle, Mrs. Robert F. 815 Griffin,

Nugent, Mrs. Milton 924 Riverview Ave.,
Oja, Mrs. Karl
Orchard, Mrs. Welland j.

Orr, Mrs. August C. 922 9th St.,

Owens, Mrs. P. L. 1214 N. 4th St.,

Perrin, Mrs. Edwin D. 520 Ave. A West,

Peters, Mrs. Clifford H. 805 N. Griffin,

Pierce, Mrs. Willard B. 911 Ave. C West,
Ramstad, Mrs. N. Oliver (W) 824 N. 4th St.,
Samuelson, Mrs. Albert F. (N)

1121 N. 1st St.,

Schoregge, Mrs. C. W. 221 N. 5th St.,

Schoregge, Mrs. Robert 1420 Ave. E East,
Smeenk, Mrs. H. P. 1107 Ave A East,

Smith, Mrs. Clyde L. 622 Raymond Ave.,
Thompson, Mrs. Arnold M. 610 Ave. A East,
Tudor, Mrs. Robert B. 714 Ave. C West,
Vinje, Mrs. Edmund G.

Vonnegut, Mrs. Felix F.

Waldschmidt, Mrs. Reuben

600 N. Washington,

Zukowsly, Mrs. Anthony

Bismarck

Bismarck

Bismarck

Ashley

Linton

Bismarck

Bismarck

Bismarck

Bismarck

Bismarck

Bismarck

Bismarck

Bismarck

Bismarck

Bismarck

Bismarck

Bismarck

Bismarck

Hazen

Linton

Bismarck

Steele

Southwest District

Bowen, Mrs. Jessie (W)
Buckingham, Mrs. William

Bush, Mrs. C. A

Curiskis, Mrs. A. A.
Dukart, Mrs. C. R.

Dukart, Mrs. Ralph
Foster, Mrs. Keith
Gilliland, Mrs. Robert . .
Gilsdorf, Mrs. Amos (N)
Guloien, Mrs. Hans
Gumper, Mrs. A. |.
Hanewald, Mrs. Walter
Hankins, Mrs. Robert
Hill, Mrs. Simon
Knickerbocker, Mrs. W. |.
Larsen, Mrs. Harlan
Nachtwey, Mrs. A. P.
Ordahl, Mrs. Norman

221 7th Ave. W., Dickinson
Elgin
Beach
Elgin

208 4th Ave. W., Dickinson
.443 1st Ave. E., Dickinson
5 E. 2nd St., Dickinson
446 1st Ave. W., Dickinson
990 3rd Ave. W„ Dickinson
41 5th Ave. W., Dickinson
7 E. 4th St., Dickinson
Richardton
Mott
Regent

( N ) . Hettinger

1005 5th Ave. W., Dickinson
115 5th Ave. W., Dickinson
Box 805, Dickinson

Raasch, Mrs. Richard F.
Reichert, Mrs. Donald
Reichert, Mrs. Larry
Rodgers, Mrs. R. W.
Spear, Mrs. A. E.

Smith, Mrs. Oscar
Thom, Mrs. Robert (N)

30 W. 8th St.,
1010 5th Ave. W„
.543 1st Ave. W.,
146 W. 6th St.,
610 1st Ave. W.,
509 1st Ave. W.,

Stutsman District

Artz, Mrs. P. G. .502 4th Ave. S.E.,

Beall, Mrs. John A. 421 4th Ave. S.E.,

Boosalis, Mrs. Nicholas (N) State Hospital,
Elsworth, Mrs. John N. 605 5th St. N.E.,
Freeman, Mrs. John State Hospital,

Hieb, Mrs. Edwin (N) 300 6th Ave. N.E.,

Hogan, Mrs. Clifford W. 316 4th Ave. N.E.,
Holt, Mrs. George (W) 214 2nd Ave. S.W.,

Jansonius, Mrs. John 609 4th Ave. S.E.,
Larson, Mrs. Ernest J. 321 2nd Ave. S.E.,
Lucy, Mrs. Robert 420 4th Ave. S.E.,

McFadden, Mrs. Robert L.

910 3rd Ave. N.W.,

Miles, Mrs. James V. (N)

722 6th Ave. S.E.,
Nierling, Mrs. R. D. 415 9th St. S.E.,

Oster, Mrs. Ellis

Pederson, Mrs. T. E. 416 4th Ave. N.E.,
Saxvik, Mrs. Russel O. State Hospital,

Sorkness, Mrs. Joseph 318 3rd Ave. S.E.,
Swenson, Mrs. John 240 12th Ave. N.E.,
Turner, Mrs. Neville (N)

Van der Linde, Mrs. John 209 N.E. 3rd,
Van Houten, Mrs. II. W.

Woodward, Mrs. Robert 602 4th Ave. S.E.,
Young, Mrs. John 505 3rd Ave. S.E.,

Traill-Steele District

Chase, Mrs. Hazel H. (W)

Knutson, Mrs. Esther L. (W)

LaFleur, Mrs. H. A.

Little, Mrs. R. C.

McLean, Mrs. R. W.

Mergens, Mrs. D. N.

Rosenberg, Mrs. Mervin
Vandergon, Mrs. K. V.

Dickinson

Dickinson

Dickinson

Dickinson

Dickinson

Dickinson

Bowman

] amestown
] amestown
Jamestown
Jamestown
Jamestown
Jamestown
Jamestown
Jamestown
J amestown
Jamestown
Jamestown

Jamestown

Jamestown
J amestown
Ellendale
Jamestown
Jamestown
Jamestown
Jamestown
LaMoure
Jamestown
Oakes
Jamestown
Jamestown

Mayville
Buxton
Mayville
Mayville
Hillsboro
Hillsboro
North wood
. . Portland

448

THE JOURNAL-LANCET

Section on PAIN

oreivord Although most physicians think of migraine as headache, it is of real interest that
in the paper entitled, “Unusual Manifestations of Migraine,’’ Dr. |ohn F. Briggs
and Dr. James Bellomo have discussed the manifestations of migraine when the
pain occurs in areas other than in the head.

John S. Lundy, M.D.

Unusual Manifestations of Migraine

o

JOHN F. BRIGGS, M.D., and JAMES BELLOMO, M.D.
St. Paul, Minnesota

The classical migraine seizure is easily rec-
ognized. Unfortunately, emphasis has been
placed so frequently on the “classical features
that many of the atypical and equivalent forms
of migraine are not recognized. The mechanism
producing migraine still remains incomplete, but
sufficient evidence indicates that the attack is
initiated by cerebral vasal constriction followed
then by vascular dilatation. In addition, there is
a strong hereditary element, and the person
afflicted with migraine has a personality that
seeks and creates stress and strains and yet, at
the same time, is unable to respond to the stress
and strains. We have been impressed by the
number of patients who have atypical migraine
as well as true migraine seizures. For this rea-
son, we wish to record some of our observations
in individuals suffering from migraine.

Many tvpes of aura have been described in
association with migraine. Some of these have
been most unique and, at times, so disturbing
to the patient that he seldom relates them to the
attending physician. The feeling of body dis-
association or alteration in body size occasionally
initiates the seizure. The feeling either of eu-
phoria or pronounced depression may be the
aura in many patients. Auditorv hallucinations
are very unusual. In one patient, each seizure of
migraine is heralded by “I hear a trumpet play-
ing in the distance, and it always seems to play
the William Tell Overture.” The patient did not
recognize the significance of this auditory phe-
nomena until a number of migraine seizures

john f. briggs is associate professor of clinical medi-
cine at the University of Minnesota, james bellomo
is a St. Paul internist.

followed this auditory hallucination. The patient
stated that when she first discussed this particu-
lar problem with her physician and family, they
suspected that she was mentally disturbed. It
wasn't until later that she had sufficient courage
to point out that she knew that the auditory
phenomena was followed by a classical migraine.
A physician related to us that he has had attacks
of migraine heralded by the sound of a jet bomb-
er appearing first in the distance and then the
roaring noise of the jet increasing in severity as
it seemingly passed over his head. This was
followed by an attack of migraine.

Many neurologic phenomena are associated
with migraine. Hemiplegia is occasionally as-
sociated with migraine. A student nurse who
has been a victim of migraine for many years
had left hemiplegia in association with her mi-
graine attacks. These were so focal in nature
that they suggested the possibility of a cerebral
lesion, but repeated studies failed to confirm this
impression. Secondary Baynaud’s phenomena has
also been found in association with migraine.
A physican who suffered from migraine noted
that the seizures were always associated with
a Raynaud’s phenomena in his left hand. Numb-
ness and tingling and other paresthesias are not
uncommon during a migraine attack.

Precordial migraine occurs frequently. In these
patients, the cephalalgia is many times less prom-
inent than the cardiac symptoms. Patients may
exhibit chest pain, palpitation, extrasystolic ar-
rhythmia, and paroxysmal tachycardia in associa-
tion with the seizure. Failing to recognize the
disturbance as part of the migraine phenomena,
the diagnosis of coronary disease has been made
erroneously in a number of these patients.

OCTOBER 1958

449

Section oh PAIN

Paroxysmal attacks of vertigo associated with
tire cephalalgia as a migraine equivalent occur
frequently after the menopause. These may also
occur in men past middle age. A careful history
of these paroxysmal attacks reveals that the
patient has experienced severe migraine in the
past or that the present attacks are similar to
those that he had with the atypical migraine but
that now only an occasional, mild headache is
associated with the vertigo. This is often so
mild that the patient fails to recognize the head-
ache because of the distress from his dizziness.

Periodic vomiting in children may be a mani-
festation of migraine. Vomiting may occur in in-
fancy or as the child grows older. In one in-
stance, the periodic attacks of vomiting and ab-
dominal pain in a child were so severe that the
child required hospitalization. Careful question-
ing of the child revealed that the attack started
with a headache onlv and was followed later by
abdominal pain, nausea, and vomiting. The
mother suffered from severe migraine, and other
members of the family had histories of migraine.
The child was later seen with typical attacks of
migraine.

Pain in the back of the neck and occipital area
is not an uncommon manifestation of migraine.
This occipital myalgia may be so severe that it
is impossible for the patient to move his head.
After the cephalalgia ceases, the pain in the neck
and the muscles of the scalp may remain or may
he associated with paresthesia in this area. The
periodic occurrence of the cervical phenomena
without headache or in conjunction with a mild
headache often leads to an erroneous diagnosis.

Torticollis in association with migraine has
also been recognized. One patient who suffered
from classical migraine frequently had a severe
torticollis occur with the cephalalgia. In addi-
tion, she had periodic torticollis with onlv a mild
headache, but all the other classical manifesta-
tions of the migrane were present.

Abdominal migraine has also been recognized.
In these cases, the abdominal symptoms may
surpass and overshadow the cephalalgia or both
may be present to the same degree. Occasionally,
the same patient may have a cephalalgic form
of migraine and, on other occasions, the abdomi-
nal form of migraine. One of our patients has
classical migraine associated with epigastric pain,
which is more severe in the upper right quad-
rant, radiating to the back and mimicking chole-
cystic disease. These seizures were typical of
a gallbladder colic. After careful study and re-
evaluation and despite the presence of normal

cholecystograms, a cholecystectomy was per-
formed. The gallbladder proved to be normal.
Following the removal of the gallbladder, the
patient still had the identical type of pain in
association with her migraine attacks. We have
seen this happen on a number of occasions, and
we call this a cholecystic type of abdominal mi-
graine.

A physician who had suffered from classical
migraine for years had an unusual type of ab-
dominal migraine. In the classical seizure, the
patient found that the attack was always initi-
ated by a euphoric aura. During this time, he
could carry out endless amounts of work and
had tremendous psychomotor activity. When
this occurred, his wife knew he would suffer
from a headache the next day. After this aura
and psychomotor activity, the patient woidd be
seized with a violent cephalalgia with all of the
associated phenomena of a migraine attack. On
other occasions, he had periodic attacks of very
severe epigastric pain with projectile vomiting.
He had had many gastrointestinal studies done
to find the cause of this recurring epigastric dis-
tress. It was found that both the patient and his
wife recognized that these abdominal attacks
were associated with a peculiar aura. Before
these attacks occured, the patient was seized
with a peculiar appetite. He became euphoric,
and his psychomotor activities increased. He
then ate such unusual meals as pickled pigs feet,
pickled herring with potatoes, and salt mackerel
with boiled potatoes. Following the ingestion of
these unusual food combinations, the natient was
seized by terrific abdominal pains with projectile
vomiting and occasionallv diarrhea. When seen
in one of these seizures, he was acutelv ill and,
interestingly enough, had his room darkened.
He stated, “When I have these attacks, the light
hurts my eyes.” When questioned as to whether
or not he had a headache, he said, “Yes, I have
a headache, but I think it comes from the effort
to vomit.” On further questioning, each one of
these seizures was found to be associated with
the headache, and, at times, lie had a tvpical
migraine cephalalgia with the attack. Once the
association was pointed out to him. he recognized
that the abdominal attack represented an un-
usual form of his migraine.

Diarrhea may also be a manifestation of mi-
graine. A railroad worker had tvpical cephalalgic
seizures which were associated with periodic
diarrhea. At other times, the periodic diarrhea
played a prominent role, and the cephalalgia
was mild or absent.

450

THE JOURNAL-LANCET

Section on PAIN

Migraine may also be associated with epilepsy.
In some patients, the use of the anticonvulsive
agents decreases the number of migraine seizures.
A man who has suffered from classical migraine
for years has, in addition, episodes of grand mal
and petit mal epilepsy. It is interesting to note
that the migraine seizures are decreased in fre-
quency while he is taking anticonvulsive agents.
A woman who has had classical migraine for
years also suffers from petit mal and grand mal
epilepsy. She, too, has a noticeable decrease in
the migraine seizures while on anticonvulsive
agents.

A disease which may be confused with mi-
graine is caused by cerebral angiomata. In these
patients, headaches recur which are not typical
of migraine, and there is an associated focal type
of epilepsy. Furthermore, there may be pressure
symptoms from the aneurysm or angiomata or
from the effects of bleeding from such a tumor.

A married woman who suffered from classical
migraine also suffered from typical grand mal
and petit mal forms of epilepsy. At no time
was there any evidence of focal epilepsy. A very
severe headache developed, which she recog-
nized as being different from migraine and also
different from any other headache that she had
had. The pain increased in severity so that she
entered the hospital and, under symptomatic
treatment by her family physician, she recovered
and was about to go home when she suddenly
became paralyzed. Physical examination reveal-

ed a subarachnoid hemorrhage, and, at autopsy,
a ruptured aneurysm was found in the circle
of Willis. Investigations before her death failed
to show the presence of any intracranial lesion,
and at no time did this patient fit the “angio-
mata epileptic syndrome.”

Renal migraine also occurs. In these patients,
the associated symptom with the cephalalgia is
that of a renal colic. Another married woman
who suffered from classical migraine had typical
renal colic pain associated with her migrane at-
tacks. On occasions, the renal colic phenomena
predominated, and the cephalagia was of minor
importance. Careful urologic investigation failed
to reveal any evidence of renal disease. A man
suffering from migraine also had renal phe-
nomena with the cephalalgia. Pain developed in
the flank, radiated down into the testicle and the
groin, and was associated with polyuria. Re-
peated urologic investigations failed to reveal
any disturbance in the urinary system. Occasion-
ally, the attacks occurred in the absence of the
cephalalgia.

CONCLUSION

Emphasis is placed on the fact that in addition to
the classical seizure, many variants of migraine
occur. At times, these equivalents may pre-
dominate, thus overshadowing the cephalalgia.
At other times, the cephalalgia may be absent
and the variant present. Our personal experience
with these variants has been related.

Book Reviews on Pain

PHYSICS FOR THE ANAESTHETIST INCLUDING A
SECTION ON EXPLOSIONS, by Robert Macin-
tosh, F.F.A.R.C.S., M.D., Nuffield professor of anaes-
thetics, University of Oxford; William W. Mushin,
F.F.A.R.C.S., professor of anaesthetics, Welsh Na-
tional School of Medicine, University of Wales; H. G.
Epstein, Ph.D., F.F.A.R.C.S., first assistant, Nuffield
department of anaesthetics, University of Oxford, ed.
2, 1958. Springfield, Illinois: Charles C Thomas, 443
pages. $15.50.

In the preface to the current edition, the authors write,
among other things: “It has often been said that teach-
ing is the best wav of learning. Twelve years ago anaes-
thetists visiting this department often propounded ques-
tions involving the application of physics to our specialty.
When we didn’t know the answers we found it a helpful
discipline to clarify our minds by referring to the proper
sources. Our difficulty often turned out to be reconciling
scientifiic accuracy with simplicity and brevity. A state-
ment accurate enough to satisfy the scientist might be
too ponderous for the clinician whose previous training

had not prepared him to digest such unpalatable fare.
Eventually we felt pen should be put to paper, and in
this book we set out to increase the anaesthetist’s ap-
petite for knowledge by making the diet more attractive.”
The objectives of the work thus defined have been ac-
complished. This book has been much needed for a long
time. It helps to fill in some important lacunae that ex-
isted for many years in the field of basic sciences as
related to anesthesiology. Pharmacology and chemistry,
in this peculiar respect, have been covered rather well in
previous writings and now physics is presented ade-
quately in the volume at hand. This book will not be
read easily by those who have been out of school a long
time, but the subject can scarcely be more simplified
than it has been in this book. The many illustrations,
brief text, and excellent selection of examples contribute
to mastery of the subject by the reader. This is really
necessary reading for anyone intimately concerned with
anesthesiology. It is indeed compulsory reading for any
anesthesiologist who wishes to do research if he plans
to employ physical means. John S. Lundy, M.D.

OCTOBER 1958

451

Section on PAIN

Current Literature on Pain

THE PREVENTION, RECOGNITION AND TREAT-
MENT OF POSTOPERATIVE ATELECTASIS, by
P. A. Clayton: ). Am. A. Nurse Anesthetists 24:254-
258, 1956.

“The most common of all postoperative pulmonary com-
plications is atelectasis .... Prevention of the disease
is always better than treatment if prevention is possible
. . . . The skill of the anesthetist is of primary impor-
tance as compared to the type of agent used ....

“If atelectasis is not recognized as an immediate com-
plication of the surgery and anesthetic, it characteris-
tically appears in about forty-eight hours. Pain is not
common but a desire to cough is. Evidence of oxygen
want is usually present as is some degree of cyanosis,
shortness of breath, labored respirations, and an increase
in pulse. Anv patient with a temperature of 101° or
above must be considered as a suspect. The most impor-
tant sign is asymetric chest movement. Usually, with
such a patient, if treated immediately, there is not too
much trouble and results are good. With the patient
turned with the affected side up, a little pounding on
the chest over the involved area may be enough to dis-
lodge the mucus, cause it to move, and thus stimulate a
coughing spell. Deep breathing with a good cough may
do the trick. If the patient is uncooperative and refuses
to cough due to pain, supporting the incision with one
hand and the other placed behind the back makes it
easier. Sometimes a visit just after a hvpo will find the
patient feeling more comfortable, and he will be more
in the mood to cooperate. If these efforts are not suffi-
cient, carbon dioxide-oxygen inhalations may stimulate
breathing sufficiently to move the mucus slightly and
thus set up a coughing spell. It may be necessary to
resort to all these maneuvers. If the patient is semi-
comatose and unable to cooperate, it may be necessary
to pass a suction catheter into the trachea, which always
sets up coughing and at the same time the secretions can
be sucked out.”

From John S. Lundy and Florence A. McOuillen: Anesthesia

Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 38. Copyright by John S. Lundy.

CIRCULATORY RESPONSES DURING ANESTHESIA
OF PATIENTS ON RAUWOLFIA THERAPY, by
C. S. Coakley, Seymour Alpert, and |. S. Boling:
J.A.M.A. 161:1143-1144, 1956.

“The purpose of this study is to point out the possible
hazard present in cases of hypertensive surgical patients
on Rauwolfia therapy .... All types of surgery and
both major and minor procedures were performed on this
group of patients. The criterion used to evaluate signifi-
cant circulatory changes during anesthesia for patients
receiving one of the reserpine drugs is blood pressure
depression greater than 40 mm. Hg associated with a
Dulse rate falling below 60 per minute, or 20 per minute
below the preoperative rate. The hypotension and brady-
cardia occurred during induction of anesthesia.

“Forty surgical patients received one of the Rauwolfia
alkaloids: 24 showed no significant circulatory changes;
15 had circulatory changes fulfilling the criterion outlined
above; and in 1 the blood pressure level and pulse rate
fell after premedication. Thus, in a total of 40 patients,

16 had severe circulatory depressions not associated with
the surgical procedure but following premedication and
use of anesthetics ....

“Electrocardiographic tracings have shown ischemic
myocardial changes .... Patients on Rauwolfia thera-
py who are to undergo elective surgery should not re-
ceive this drug for two weeks prior to the surgical pro-
cedure. The hazards of removing the antihypertensive
and tranquilizing effects of these drugs must be consid-
ered before discontinuing therapy prior to a surgical
procedure. Emergency surgery on these patients may be
safely carried out by using vagal blocking drugs to pre-
vent and treat vagal circulatory responses.”

From John S. Lundy and Florence A. McQuillen: Anesthesia

Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, pages 38-39. Copyright by John S. Lundy.

NITROUS OXIDE, TRICHLORETHYLENE, AND
ETHER: A BALANCED ANESTHESIA IN OB-
STETRICS, by L. N. Cheeley: Anesth. & Analg. 35:
422-424, 1956.

“In the hospital in which the author works (Oil City
Hospital, Oil City, Pa.), the anesthesia gas machines do
not have carbon dioxide absorption units on them, and
the 'Trilene’ and the ether vaporizers are attached in
series to the gas line. The ether jar is attached directly
to the gas line and is of the ‘wick’ type. Next in line
is the ‘Trilene’ jar which contains no wick. The ‘Trilene’
is vaporized by the passage of gases over the surface of
the ‘Trilene.’ Thus, we have two anesthetic agents, ‘Tri-
lene’ and nitrous oxide, both of which, when used prop-
erly, are safe agents and have very little effect on the
newborn infant. There is only one quality lacking, i. e.,
potency. To add potency to this mixture and to give
greater controllability and muscular relaxation, it seems
logical to add ether vapor ....

“To avoid postpartum nausea and vomiting, using the
nitrous oxide-oxygen-triehlorethvlene and ether technique,
the ether is shut off as soon as the baby is born . . . .
The advantages of this technique may be summarized
thus: 1. Ready controllability of depth of anesthesia.

2. Anesthetic agents in the dosages prescribed are rela-
tively nontoxic and are readily eliminated. The postpar-
tum recovery period is shortened. 3. The baby is little
affected by anesthetic agents. 4. Nausea and vomiting
are minimal.”

From John S. Lundy ard Florence A. McQuillen: Anesthesia

Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 37,. Copyright by John S. Lundy.

PHYSIOLOGY OF THE ADRENAL GLAND, bv J. 11
Burn: Brit. J. Anaesth. 28:459-469, 1956.

“In the course of evolution, chromaffin tissue and the
tissue of the adrenal cortex, formerly two separate organs,
have been brought together into one organ, the adrenal
gland .... The active principles of the cortex which
are found in the adrenal vein in man are believed to be
there: namely, hydrocortisone, corticosterone, and aldos-
terone. These are hormones with a steroid structure,
much more complicated than that of noradrenalin and
adrenalin. The first, hydrocortisone, represents 80 per
cent, the second represents 20 per cent, and the third less
than 1 per cent of the active substances liberated . . . .

452

THE JOURNAL-LANCET

Section on PAIN

“These different substances all share the property of
prolonging the life of young adrenalectomized rats when
exposed to cold. This property depends on the rapid for-
mation of carbohydrate from protein and is known as
glucocorticoid activity .... Another property possessed
by the adrenal cortex is that of controlling the excretion
of sodium by the kidney ....

“Another property of the cortical hormones is that
when released in the blood they cause a fall in the num-
ber of eosinophil cells in circulation. Since the physio-
logical significance of this change is uncertain, this prop-
erty is mentioned only because it may also be used to
compare the different hormones of the adrenal cortex.
. . . . Aldosterone has from one-quarter to one-half the
potency of cortisone, and cortisone is equal in action to
hydrocortisone ....

“The observations of Hench, Kendall, Slocomb, and
Pulley (1949) showed that cortisone had a powerful ef-
fect in restoring the mobility of the joints in rheumatoid
arthritis. This is generally regarded as an effect due to
the dissolution of inflammatory exudate and to the dis-
appearance of fibrous tissue around the joints and is con-
sidered as one aspect of the action of cortisone in sup-
pressing inflammatory processes. There seems to be no
doubt that cortisone and hydrocortisone when given in
large doses can lower the resistance of both animals and
men to certain forms of infection ....

“Other effects of cortisone and of hydrocortisone have
definite clinical value in suppressing various phenomena
which may be grouped as allergic .... The hormones
of the adrenal cortex are released when the pituitary
gland is removed, but the rate of secretion then remains
constant .... Much greater amounts of the cortical
hormones are liberated in conditions of stress ....

“Under conditions of stress we may note that the hor-
mone of the adrenal cortex and of the adrenal medulla
support one another. Thus hydrocortisone facilitates the
conversion of protein to carbohydrate, while adrenalin
breaks down glycogen to glucose. Again it has been dem-
onstrated that cortisone ( and therefore hydrocortisone )
is required to maintain the blood-pressure-raising action
of noradrenalin ....

“There are several steroid substances capable of di-
minishing the symptoms of cortical deficiency . . . .
The substance which offers the greatest promise, how-
ever, is aldosterone, which removes all the symptoms of
adrenal insufficiency; namely, fatigue, nausea, anorexia,
sleepiness, depression, and the dyspnoea which occurs
on making an effort ....

“Besides diseases due to cortical deficiency, there are
some due to hormone excess .... Adrenalin is formed
from noradrenalin by the substitution of a — CIT group
for hydrogen in the — NH; group .... The importance
of the change from noradrenalin is very great. In the
first place, noradrenalin has little or no Dower to cause
a discharge of ACTH from the anterior lobe, and with-
out adrenalin the power to augment secretion of cortical

hormone in times of stress would be greatly reduced. In
the second place, adrenalin is far more efficient to dis-
charge the functions required in time of stress than is
noradrenalin ....

"A further difference between the two amines is in
their vascular action. Adrenalin causes vasoconstriction
in the skin and in the intestinal region, but in moderate
amounts it causes dilatation of the muscle vessels . . . .
The fact that noradrenalin is liberated by splanchnic
stimulation has given rise to speculation whether it has
a special function not shared by adrenalin .... There
is ... . evidence that stimulation of the hypothalamus
at one point causes the release of mainly noradrenalin
from the gland, whereas stimulation at a different point
causes the release of a large amount of adrenalin as
well .... Furthermore, there appear to be cells in the
adrenal medulla which contain noradrenalin and others
which contain adrenalin ....

“Of the working of the adrenal gland, much remains
to be discovered. We have no idea of the mechanism of
the anti-allergic action and of the anti-inflammatory ac-
tion of the cortical hormones, and of course very little
idea of how these hormones are acting when they con-
vert protein to carbohydrate or when they absorb sodium
in the kidney tubules.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, pages 31-32. Copyright by John S. Lundy.

RESPIRATORY ADJUSTMENTS TO INCREASES IN

EXTERNAL DEAD SPACE, by G. B. Clappison and

W. K. Hamilton: Anesthesiology 17:643-647, 1956.
“Although it has been a matter of common knowledge
that increases in external dead space would cause an in-
crease in tidal and minute volumes in subjects able to
increase their ventilation, the quantitative aspects of
those increases, particularly with quite small dead space
increments, have not been well delineated. This investi-
gation was undertaken to determine the effects of such
increases in external dead space on certain respiratory
functions .... Normal adult males were used as sub-
jects ....

“Dead space increases of about 125 ml. added to a
‘minimum’ external dead space of 40 cc. cause statis-
tically significant changes in tidal and minute volume and
end-expiratory pCOL. in unanesthetized normal subjects
under quiet, resting conditions. This indicates that even
in unmedicated normal subjects, the adjustments to in-
creased dead space, particularly in diagnostic and re-
search apparatus, should be considered thoroughly since
it is conceivable that less than optimum accuracy might
be obtained with increases in dead space formerly con-
sidered insignificant.”

From John S. Lundy- and Florence A. McQuili.en: Anesthesia

Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 37. Copyright by John S. Lundy.

OCTOBER 1958

453

BOOK REVIEWS

(Continued from page 424)
and promotional activities and init-
iate and help carry on a national
campaign to eradicate bovine tuber-
culosis. In 1934, he was appointed
general manager of the National
Livestock Loss Prevention Board and
held this position until his retire-
ment in 1951.

In this volume, Dr. Smith tells
how the bovine type of tubercle
bacillus entered the United States
and spread to such serious propor-
tions. His first experience with this
disease was in 1894 as a student at
Michigan Agricultural College, which
is now Michigan State University,
where pioneer work with the tuber-
culin test was being done. I le ob-
served this test to be so specific that
wherever he worked thereafter, he
insisted upon its use. He spent a
great deal of time in Washington
testifying before legislative commit-
tees on the importance of adequate
appropriations for the eradication of
tuberculosis among animals. Indeed,
he played an exceedingly important
role in procuring the first large fed-
eral appropriation for this purpose.

Despite the intense opposition to
the tuberculosis eradication program
by uninformed, misinformed, or self-
ish individuals, Dr. Smith worked
unceasingly to see that accurate in-
formation reached owners of cattle,
legislators, and all others concerned.

Tuberculin testing of cattle was
placed on a county-wide basis. The
reactors were removed, and periodic
testing was done until all of the
3,150 counties of the United States
received the modified accredited rat-
ing. This rating was awarded the
counties as fast as the incidence of
tuberculin reactors reached 0.5 per
cent or less. Ever since, periodic
tuberculin testing has been contin-
ued with the eradication of the bo-
vine type of tubercle bacillus as the
goal. This has been attained in
many places where no animal re-
acts to the tuberculin test. However,
in the nation as a whole, about 0.15
per cent of the animals react. There
is evidence that many of these ac-
quire infections from owners, farm
hands, and other human contacts.

This book also calls attention to
how the control of tuberculosis
among cattle reduced the disease
among people. Prior to 1917, many
people acquired tuberculosis from
cattle. Evidence indicates that an
important block of the incapacitat-
ing and killing disease of that period
among people was due to the bovine
tvpe of tubercle bacillus.

In 1917, Dr. John A. Kiernan,

then chief of the Division of Tuber-
culosis Eradication of the United
States Bureau of Animal Industry,
was asked how long it would take to
eradicate tuberculosis on a nation-
wide scale. He wisely answered
that there was no ground upon
which a reasonable estimate could
be made. He said, “All one can do
is to make a guess as to the time,
and it is my belief that if this nation
succeeds in eradicating tuberculosis
in fifty years, it will be one of the
greatest heritages our successors will
have handed down to them.” If the
eradication methods of the past are
continued and intensified, it seems
probable that by 1967, the bovine
type of tuberculosis will have been
eradicated from cattle. However,
unless drastic action is taken to ad-
minister the tuberculin test to people
everywhere and examine and keep
reactors under observation, as Dr.
Smith recommends, there will still
be tuberculin reactors among cattle.

The remaining problem to be
solved both among animals and
people will be the responsibility of
members of 4-H clubs and Future
Farmers of America to whom this
book is so wisely dedicated as well
as every present and future Ameri-
can youth. The book is an accurate
step by step account of a method
applied with such success that it
has been designated man’s greatest
victory over tuberculosis. With modi-
fications, it can be as effective in
eradicating tuberculosis from people.

Physicians everywhere can contri-
bute significantly in the program of
eradication of all types of patho-
genic tubercle bacilli by contacting
leaders of 4-H clubs and Future
Farmers of America in an endeavor
to place Dr. Smith’s book in posses-
sion of every member.

J. Arthur Myers, M.D.

•

The Diagnosis and Treatment of
Postural Defects, by Winthrop
M. Phelps, M.D., R. J. H. Kip-
huth, and Charles W. Goff,
M.D., 1956. Springfield, Illinois:
Charles C Thomas, 190 pages.
$6.50.

This book deals with the fundamen-
tals of posture, its evolution in the
human race, its development from
infancy to adulthood, and the vari-
ous factors which effect this devel-
opment. The factors stressed are en-
vironment, disease, congenital ab-
normalities, and abnormal stresses
and strains. The authors define nor-
mal posture for various age groups
and discuss the normal and abnor-
mal variations in each group. The

diagnosis and treatment of the more
common abnormalities are included.
The general principals of body me-
chanics are presented, which include
a thorough but practical discussion
of the anatomy and mechanics of
movement of the various joints and
regional components of the body to-
gether with the effect on the center
of gravity and posture with each
movement. The various methods
used in postural examination are ex-
plained. These include direct phys-
ical examination and measurement,
silhouettographic studies, and pos-
tural analysis by photometric means
using full body photographs in four
views and aluminum markers at-
tached to key bony landmarks.

The final chapter deals with cor-
rective exercises for strengthening
various muscles and muscle groups.
This gives detailed but easily fol-
lowed instructions in corrective ex-
ercises and indications for their use.

This book was written for school
physicians, athletic coaches, phys-
ical educators, and parents interest-
ed in the growth and development
of children. It is well written. The
pictures and illustrations are de-
scriptive. The terminology used can
be readily understood by both the
professional and lav reader.

John H. Moe, M.D.

Kaposi’s Sarcoma: Multiple Idio-

pathic Hemorrhagic Sarcoma, by
Samuel M. Bluefarb, M.D., ed-
ited by Arthur C. Curtis, M.D.,
1957. No. 308, American Lecture
Series, monograph in Bannerstone
Division of American Lectures in
Dermatology. Springfield. Illinois:
Charles C Thomas; Oxford, Eng-
land: Blackwell Scientific Publica-
tions, Ltd.; Toronto, Canada: Ry-
erson Press, 171 pages. $5.50.
This compact monograph is an ex-
cellent review of all the currently
available knowledge on this unusual
and interesting disorder. Following
brief chapters on history and de-
scriptive terms, the author discusses
various etiologic factors and pathol-
ogy, including theories regarding
pathogenesis. A considerable por-
tion of the book is devoted to clin-
ical manifestations, internal as well
as cutaneous. Diagnosis, differen-
tial diagnosis, prognosis, and vari-
ous therapeutic methods are all ade-
quately’ covered. The bibliography is
extensive and particularly complete.
This well written, nicelv illustrated
volume can be recommended to any -
one interested in this subject.

Elmer M. Hill. M.D.

454

THE JOURNAL-LANCET

Introduction to Series on

Communicable Diseases

J. ARTHUR MYERS, M.D.

The paper on “Scarlet Fever’ by Dr. L. G. Pray
in this issue is the first of a long series of articles
on communicable diseases to lie published in The
Journal-Lancet. Progress has been made in diag-
nosis, treatment, and prevention of many of these
diseases. However, one fact stands in bold relief.
Namely, none has been eradicated, and many of
them, although markedly reduced in prevalence and
destructiveness, remain constant threats to the citi-
zenry of every community. One of the objects of
this series is to keep these diseases before our readers
so that they will be on the alert should thev appear
in their communities. The accompanying table shows
number of cases and deaths in Minnesota at twentv-
year intervals since 1916.

Although efficacious smallpox vaccine has been
available since 1796, I have personally observed an
epidemic causing serious illness in a large number
of persons, 300 of whom died. Smallpox remains
one of the scourges of mankind with over 400,000
cases occurring each year among the world’s citi-
zenry. I have resided in a rural community where
previously well-documented diphtheria epidemics re-
sulted in deaths of 25 to 50 per cent of school chil-
dren. There a family monument testifies that all of

the 9 children died from this disease within a period
of three weeks. Over recent decades, periods of
years have passed there without 1 case having been
reported. However, in other years, cases have ap-
peared. Even now, more than 1,000 cases and sev-
eral hundred deaths from diphtheria occur annually
in the United States.

Illness and death from smallpox and diphtheria,
which are completely preventable, are due to such
factors as lack of information, economic situations,
opposition to preventive measures by eultists, and
public complacency.

In the United States alone, 3,000,000 persons are
said to suffer annually from contagious diseases (ex-
clusive of the common cold).

No communicable disease of human beings or
animals will be eradicated as long as its causative
organism exists. Therefore, there must be no relaxa-
tion of constant vigilance and health education.
Health workers and educators in all categories must
present information everywhere, then repeat and re-
peat and repeat. Important facts to date are pre-
sented in this series of papers which, if employed
judiciously and unsparingly, will markedly reduce
illness and death everywhere from these diseases.

Reported Cases and Deaths of Selected Communicable Diseases

(Courtesy Minnesota Department of Health)

1916

19 36

19 56

Cases

Deaths

Cases

Deaths

Cases

Deaths

Diphtheria

2,502

170

427

17

44

4

Measles

9,596

273

8,024

23

1,334

2

Poliomyelitis

912

105

37

4

150

6

Scarlet fever

4,003

117

10,556

111

975

0

Smallpox

1,256

1

397

0

0

0

Tuberculosis*

5,280

2,400

3,483

963

1,282

115

Typhoid fever

1,055

129

120

14

37

0

Whooping cough

919

234

1,705

34

123

1

“December 1956 current register 8,386 cases. Estimated 25 per cent of total population harboring bacilli = 750,000.

Communicable Diseases

Scarlet Fever

LAURENCE G. PRAY, M.D.
Fargo, North Dakota

Scarlet fever is an acute infectious disease
characterized by sudden onset of sore throat
and fever, with a subsequent erythematous rash
often followed by desquamation. It is caused by
the group A hemolytic streptococcus and, like
other streptococcal infections, may be complicat-
ed by cervical adenitis, otitis media, mastoiditis,
sinusitis, and later by rheumatic fever or acute
hemorrhagic nephritis. It is pirmarily a childhood
disease, the majority of cases occurring between
the ages of 3 and 8, with 75 per cent in children
under 10 years of age. It is uncommon in in-
fants under 1 year of age, although cases have
been recognized even during the first year of
life. It occurs in all parts of the world but is
most common in the cooler temperate zones dur-
ing the winter and spring months. Except in rare
instances, it is endemic in a community, with
sporadic cases breaking out at scattered points.
Scarlet fever has diminished in severity in recent
years, but it is still to be respected and avoided.

HISTORY

According to Topp, Angrassias of Palermo in
about 1560 is credited with being the first
person to give a clear description of scarlet
fever. Thomas Sydenham was one of the first
to describe the disease and differentiate it from
measles and other infectious diseases. This fa-
mous seventeenth century English physician con-
sidered scarlet fever a minor infection but later
appreciated its more serious nature. Others who
recognized and described scarlet fever were Sen-
nert and Doring of Germany, who lived at about
the same time as Sydenham. It is doubtful

lauhence c. pray is associated ivith the Department
of Pediatrics at the Fargo Clinic and on the staff of
St. Luke’s Hospital, Fargo.

whether scarlet fever was known at the time of
Hippocrates or during the Middle Ages.

ETIOLOGY

The streptococcus is now recognized to be the
cause of scarlet fever. This discovery was due
to the work of the Dicks and others, who repro-
duced the disease in human volunteers from cul-
tures of hemolytic streptococci. Lancefield has
classified the streptococcus into 12 or 14 sero-
logic groups on the basis of group C specific an-
tigen, a carbohydrate fraction extracted from the
streptococcus. Group A is the most pathogenic
for man, causing 90 to 95 per cent of human
hemolytic streptococcal infections. Groups C and
D organisms occasionally cause human infection
but tend to be less severe than group A infec-
tions. Group A has been subdivided into more
than 40 types on the basis of type specific M
antigen. The M antigen, a protein, is of clinical
importance because the antibodies produced
against it cause type specific immunity to de-
velop in the patient.

There are other antigens produced by the
group A hemolytic streptococcus: namely, the
erythrogenic toxin, streptolysin O, fibrinolvsin
(streptokinase), and hyaluronidase. The erythro-
genic toxin causes the rash of scarlet fever in
addition to other toxic manifestations of that
disease. Streptolysin () is produced by most
group A strains and causes hemolysis of red cells.
Fibrinolvsin may break down fibrin barriers and
result in a more rapid spread of streptococci in
the tissues. Hyaluronidase increases the absorp-
tion and spread of fluids in the body tissues and
may also tend to diffuse the organisms and toxins
throughout the body. Antibodies against strep-
tolysin O, as evidenced by a high antistreptolysin
titer, are indicative of a recent streptococcal in-

456

THE JOURNAL-LANCET

fection. This test is a standard laboratory pro-
cedure. Antistreptokinase and antihyaluronidase
in the blood serum have a similar significance.
Antibody against the C antigen can also be dem-
onstrated in the laboratory and is also indicative
of a recent streptococcal infection.

Scarlet fever and other streptococcal infections
are usually spread by droplets from the nose and
throat of an individual who is carrying the or-
ganism either as an ill patient or as a carrier.
The organisms may be coughed, sneezed, or ex-
haled into the air and, hence, directly into the
nose and throat of a nearby healthy person, caus-
ing him to contract the disease, or the organisms
may lodge in bed clothing, dust, or lint and then
be carried into the respiratory passages of indi-
viduals who have had no close contact with the
patient or carrier. The same may be said for
objects handled by an infected individual and
also for infected food handlers or dairy workers.
The difficulty of reducing the incidence of strep-
tococcal infections is evident, since it is esti-
mated that 20 per cent of children and 8 per
cent of the total population are carriers during
the winter months.

CLINICAL COURSE

Symptoms of scarlet fever begin after an incu-
bation period of two to seven days, with five
days the usual limit of incubation. Occasional
cases have been reported eight to ten days fol-
lowing contact, but these cases are not common.

The onset is characterized by sore throat and
fever, which may be mild or severe. In severe
cases, the temperature rises rapidly to 103 to
104° F. and is accompanied by an extremely sore
throat, headache, and often nausea and vomiting.
In the milder cases, more common at the present
time, the sore throat and fever and other symp-
toms are less acute so that the physician is often
not called until the fever and sore throat have
persisted for two or three days or until the rash
appears and causes concern.

The rash comes out in twelve to thirty-six
hours after the onset of other symptoms. Occa-
sionally, the rash does not appear for three to
five days, but this prolonged time interval is in-
deed rare. Characteristically, the rash is a fine,
diffuse, erythematous eruption appearing much
like a sunburn. It may be quite smooth, or it
may be granular due to swelling and elevation
of the sebaceous follicles. It may be scattered
and mild in some cases and thus be confused
with German measles. The rash occurs on the
neck, trunk, and extremities but does not usually
involve the face. The face is flushed with a cir-
cumoral pallor. In milder cases, the rash is most

pronounced in the axillae, groins, neck, and chest.
It is often accentuated in the body folds, par-
ticularly the cubital folds. These accentuated
lines are called Pastia’s lines. The rash blanches
on pressure with the fingertips, the color quickly
returning to the blanched areas when the pres-
sure is released. The rash may last only a day
or two in mild cases or as long as seven days in
cases in which the rash is severe. Desquamation
of the rash may or may not take place, and the
absence of desquamation does not rule out the
diagnosis of scarlet fever. The amount of des-
quamation is in direct proportion to the severity
of the rash as a rule. Desquamation usually
begins in about a week to ten days after the
rash first appears. It is most constant on the tips
of the toes and fingers but, in some cases, peels
off in large strips over the entire surface of the
hands and feet and in fine and large patches on
the body. It may last for a week to two weeks
or even longer.

The tongue has a heavy, grayish white coating
on the first day with fiery redness appearing at
the tips and margins of the tongue on the first
or second day. The coating clears from the tip
backward over a five- to seven-day period, leav-
ing a bright red tongue with prominent papillae,
the characteristic strawberry tongue. The straw-
berry appearance subsides in another three or
four days. The throat has an acute diffuse in-
flammation. By the second day, there are usually
Hecks of white exudate on the tonsils, which may
become larger, patchy, and thick. The exudate
is not usually present in mild cases. The anterior
pillars and soft palate have a typical redness
and blush, and there are at least a few small,
bright red hemorrhagic spots on the soft palate
during the first two or three days. The anterior
cervical lymph glands are moderately enlarged,
firm, and tender during the acute stage. Scarlet
fever occasionally starts in an infected surgical
or traumatic wound. In such cases, the charac-
teristic changes in the throat, tongue, and cer-
vical glands do not take place.

The body temperature may remain elevated
only two or three days or a week or longer, de-
pending on the severitv of the case and the type
of treatment administered. The pulse rate is
rapid during the febrile illness. The respiratory
rate is increased in proportion to the tempera-
ture and toxicity. After the temperature subsides
to normal, there is a convalescent period of a
week or ten days in which the patient’s appetite
and energy return to normal. Young children
tend to have a shorter convalescent period than
older children and adults.

Relapses have been known to occur during the

NOVEMBER 1958

457

third or fourth week of the disease, with recur-
rence of sore throat, fever, and rash. In my ex-
perience, however, such cases have occurred only
in contagious disease hospitals in which patients
with scarlet fever were exposed to one another.
Although typing of group A streptococci was not
done in these cases, reinfection was probably
not caused by the original type of streptococcus
and had taken place before erythrogenic anti-
toxin had developed in appreciable quantity.

Recurrence of scarlet fever years after the
original infection is also known to occur in rare
instances. Some authorities dispute the validity
of such recurrences, but, on clinical grounds,
there is no doubt that they do take place, prob-
ably on the' basis of low levels or loss of erythro-
genic antitoxin.

LABORATORY FINDINGS

The leukocyte count is elevated to 12,000 to
20,000 cells, with a shift to the polymorphonu-
clear leukocytes and band cells. After the first
three or four days, a characteristic eosinophilia
of 5 to 10 per cent occurs. The changes in the
white blood cell count gradually disappear as
clinical symptoms subside. There is ordinarily no
anemia even though the streptococcus is hemo-
lytic; anemia can be a factor in severe or com-
plicated cases. The sedimentation rate, antistrep-
tolysin titer, and C reactive protein all become
elevated during the acute or convalescent stage
of the disease and gradually return to normal
after four to six weeks. Antibodies also develop
against streptokinase and hyaluronidase. No lab-
oratory tests except a urinalysis are necessary in
the ordinary case of scarlet fever but may be
significant in cases of doubtful diagnosis or help-
ful as a prognostic aid.

The urine often contains moderately increased
albumin during the acute febrile illness together
with a few red blood cells per high-powered
field. These findings disappear with deferves-
cence. The urine is always tested during the sec-
ond or third week of the disease to rule out
the possibility of hemorrhagic nephritis as a
complication.

The Dick test indicates susceptibility to scarlet
fever when positive. A patient becomes negative
to the Dick test on the third day of illness. The
test is very seldom used, but should be kept in
mind and applied in doubtful cases. It consists
of the intradermal injection of standardized
streptococcus toxin containing 1 skin test dose
in 0.1 cc. A positive reaction is shown by an
area of erythema measuring at least 1 cm. in
diameter after twenty-four hours.

The Schultz-Charlton test is another diagnostic

test for scarlet fever and consists of injecting
.2 cc. of scarlet fever antitoxin or .5 cc. of con-
valescent or immune serum intradermally into
the rash. This causes the rash to blanch in four
to twenty-four hours for several centimeters
around the injection site.

COMPLICATIONS

Complications are much less frequent now than
formerly, probably due both to the milder form
of scarlet fever now being seen and to the
prompt and effective use of antibiotics in treat-
ing the disease. However, they still occur and
must be watched for and guarded against.

The most common complication is acute otitis
media, as the streptococcus has a pronounced
tendency to invade the middle ears. If not ade-
quately treated, otitis media may, in turn, invade
adjacent structures, causing mastoiditis, brain
abscess, lateral sinus thrombosis, and meningitis.
Sinusitis is not uncommon and occurs when the
infection spreads from the nose into the adjoin-
ing sinuses. Streptococci may occasionally in-
vade the larynx, trachea, and bronchi or even
cause pneumonia. Cervical lymphadenitis ranks
along with otitis media as a common complica-
tion. The anterior cervical lymph glands are
usually enlarged at least to some extent during
the acute illness but subside to normal after the
first week. However, acute suppurative lymph-
adenitis occurs occasionally and has to be treated
early with local warm applications and large
doses of antibiotics. If the process advances to
the point of softening, incision and drainage must
be carried out.

Streptococci may metastasize through the
blood stream to distant parts of the body during
the acute stage of scarlet fever, causing osteo-
myelitis, endocarditis, myocarditis, pericarditis,
septicemia, tissue abscess formation, suppurative
arthritis, or brain abscess. Carditis may also be
toxic early in the disease, with cardiac weakness,
dilatation, tachycardia, arrhythmia, and failure.

Acute rheumatic fever and acute hemorrhagic
nephritis may develop during the second or third
week after the onset of scarlet fever. The etiology
of both diseases is not definitely established, but
they are thought to be an allergic reaction to the
streptococcus or its toxin. There is no need to
discuss the care of either of these diseases, but
one must be on the alert for them following scar-
let fever. The incidence of these complications
has dropped sharply in the last ten or fifteen
years. It is the writer's opinion that the present
incidence is not more than 2 or 3 per cent. Rheu-
matic fever is ushered in by lassitude, fever, and
transient or migratory polyarthritis. In some

458

THE JOURNAL-LANCET

cases, arthritis is mild or absent, and an apical
systolic murmur of mitral insufficiency is the first
positive evidence of rheumatic fever. The sedi-
mentation rate is markedly increased in both
rheumatic fever and nephritis. Nephritis is at-
tended bv edema, hypertension, and malaise, to-
gether with albuminuria, red blood cells, and
casts in the urine.

DIFFERENTIAL DIAGNOSIS

Mild cases of scarlet fever are often difficult
to differentiate from rubella. The latter is the
disease that most often raises the question of
whether or not one is dealing with a mild scarlet
fever. The rash of rubella may be very similar
to that of mild scarlet fever, and the clinical
symptoms are not unlike those of scarlatina. The
white blood cell count and differential smear are
of help in separating the two diseases, as rubella,
which is a virus disease, is accompanied by leu-
kopenia and lymphocytosis. A throat culture con-
taining group A hemolytic streptococcus also es-
tablishes the diagnosis of scarlet fever. Erythe-
ma infectiosum and roseola must also be ruled
out at times.

Scarlatiniform eruptions may occur from such
drugs as salicylates, penicillin, atropine, anti-
pyrine, and others. Some cases of urticaria and
serum sickness may cause a rash similar to that
of scarlet fever. Infectious mononucleosis, influ-
enza, and typhoid fever are examples of diseases
which occasionally manifest a scarlatiniform
eruption. Of course, in all of these conditions,
the typical findings in the throat and on the
tongue are lacking as well as typical clinical
manifestations.

A Dick test or Schultz-Charlton test is helpful
in selected cases. Another test is the tourniquet
test, in which a tourniquet is applied tightly
around the arm above the elbow for two or three
minutes. The presence of numerous petechiae
below the constricted site is supposed to be
characteristic of scarlet fever ( Rumpel-Leede
sign), but there is some question as to whether
this is a reliable criterion of the disease.

Occasionally, a doubtful case is seen in which
desquamation is later of help in establishing the
diagnosis. If there is doubt about the diagnosis
of scarlet fever, the disease should be tentatively
diagnosed and proper isolation precautions and
treatment maintained until the disease is proved
not to be scarlet fever.

TREATMENT

Bed rest and penicillin are the two most impor-
tant factors in treatment. All authorities agree
that rest in bed is necessary at least until the

temperature has been normal for a week. It
seems that this may be a little longer than nec-
essary in a mild case, and, in such cases, a total
period of bed rest of a week is probably enough
followed by another week of reduced activity
at home. In severe or complicated cases, there
is no doubt that prolonged bed rest for several
weeks may be needed. With the present well-
justified trend toward shorter isolation periods,
one must remember that the complications usu-
ally occur in the second or third week. It is our
practice to examine every child with scarlet fever
during the second or third week after onset, after
he has been clinically well for approximately a
week. Urinalysis is done at that time together
with a complete physical examination as well as
a hemoglobin, sedimentation rate, and complete
blood count if indicated by the patient’s physical
examination and general condition.

Penicillin is the antibiotic of choice in scarlet
fever, as the group A hemolytic streptococcus is
almost always susceptible to it. As in other group
A streptococcal infections, treatment should be
continued for ten days. This can be done in one
of several ways. Aqueous procaine penicillin
may be given intramuscularly in a dosage of
600,000 units every other day for 3 or 4 injec-
tions. Oral penicillin, such as V-cillin K can be
administered in a dosage of 125 to 250 mg.
three times daily for ten days. A single dose of
long-acting benzathine (Bicillin), 600,000 units,
may be combined with an equal amount of pro-
caine penicillin to give a high blood level for
forty-eight hours followed by a lower sustained
effect long enough to eliminate the streptococcus
from the throat and tissues. The sulfonamides,
erythromycin, tetracycline, or teracycline V,
Chloromycetin, Terramycin, or Aureomycin may
be given in place of penicillin to patients sus-
pected of being sensitive to penicillin. These
agents must be continued for the same length of
time as penicillin in appropriate dosage for age.

The treatment of the complications of scarlet
fever need not be discussed here except to em-
phasize that prompt and adequate use of peni-
cillin, other antibiotics, or sulfonamides has been
an important factor in reducing the incidence of
all complications, toxic as well as septic or bac-
terial. This is true even though antibiotics have
no antitoxic properties. By their bactericidal or
bacteriostatic action, they reduce the formation
of toxins as well as bacterial growth and spread.

PREVENTION

Inasmuch as scarlet fever is potentially a serious
disease, every reasonable attempt should be
made to prevent its occurrence. For example,

NOVEMBER 1958

459

when a case breaks out in a home, other mem-
bers of the family should take prophylactic peni-
cillin for five days in a dosage of 125 to 250 mg.
of V-cillin or V-cillin K twice daily. Intramus-
cular long-acting Bicillin serves the same pur-
pose in a dosage of 600,000 to 1,200,000 units,
depending on age. Other antibiotics or sulfona-
mides may be given to individuals resistant or
allergic to penicillin in a dosage not to exceed
half of the therapeutic dose and divided in 2
daily doses for five days. Prophylaxis should be
given even to exposed individuals who have had
scarlet fever, as they are susceptible to all symp-
toms of streptococcal disease except the rash.
Exposed school children among family contacts
should be kept at home for a week out of con-
tact with the patient and be examined by a phy-
sician before returning to school. Present recom-
mendations allow parents to continue their nor-
mal activities and work, providing they are not
food handlers or in close contact with children.

Children who have had casual contact with
a case of scarlet fever, such as in school, should
take prophylactic antibiotics as already outlined
but need not be excluded from school. If a num-
ber of cases should break out in a school or
school room, it might be necessary to close the
school or the room for about two weeks as an
added safeguard. This is seldom necessary, how-
ever, as most cases occur sporadically and not in
massive epidemic form.

Proper isolation of the patient himself is essen-
tial. He should be in a room by himself during
the infectious stage of the disease and be cared
for by only one person, preferably the mother,
who uses care not to spread the germs on her
clothing or hands. This is best done by wearing
a gown or apron when taking care of the child
and washing the hands before leaving the room,
both before and after removing the apron or
gown. The physician has an obligation to the
patient and to the community to continue treat-
ment and isolation precautions until he can be
sure that active infection has subsided. A mini-
mum of one week isolation is presently recom-

mended by most authorities. This minimum iso-
lation period often has to be doubled and some-
times tripled. Even in mild cases, a child should
not return to school in less than two weeks after
onset of the disease, chiefly for his own protec-
tion against possible complications.

Active immunization against scarlet fever has
been carried out to a limited extent in the past
but is no longer recommended. To do this, Dick
scarlet fever toxin is given subcutaneously once
a week for five weeks. Systemic reactions to this
procedure are often severe, and the protection
afforded is primarily against the rash and not the
streptococcal infection, so that most authorities
at present advise against its use.

PROGNOSIS

The mortality rate of scarlet -fever has been fall-
ing steadily during the past twenty years with
the use of sulfonamides, penicillin, and other
antibiotics. Those who treated scarlet fever prior
to that time can recall the frequent myringoto-
mies, incisions of abscesses, and mastoidectomies,
with more serious complications and death a too
common final outcome. While scarlet fever in
general is a milder disease now, it is possible
that it would resume its more serious aspects
if our present antibiotics were not available.
Those who have had to depend on scarlet fever
antitoxin and convalescent serum can recall the
doubtful results obtained with such treatment.
The present mortality rate is said to be 1 or 2
per cent but is probably even lower. When death
occurs, it is usually in the younger child or in-
fant who has not had the benefit of prompt treat-
ment. Death is ordinarily the result of septic-
complications and occurs during the first week
or ten days of illness.

BIBLIOGRAPHY

1. Smythe, F. F.: Scarlet fever, in Holt, L. E., Jr., and Mc-
Intosh, R.: Pediatrics. New York: Appleton-Centurv-Crofts,

Inc., 1953, vol. 12, p. 1298.

2. Bradford, W. W.: Scarlet fever, in Nelson, W. E.: Text-

book of Pediatrics. Philadelphia: W. B. Saunders Co., 1954.
vol. 6, p. 365.

3. Topp, F. H.: Scarlet fever, in Brennemann-McQuarhie :

Practice of Pediatrics. Hagerstown, Maryland: W. F. Prior

Co., vol. 2, chapter 23, 1954.

460

THE JOURNAL-LANCET

Treatment of Recurrent Convulsions
in Children

HADDOW M. KEITH, M.D.

Rochester, Minnesota

Many children with convulsive disorders
can be treated successfully by present-day
methods. Before 1900, the bromides were the
only fairly effective drugs, and, in rare cases,
traumatic epilepsy was helped by surgical treat-
ment. At present, at least 15 drugs are known
to be effective; several others are helpful at
times; and new anticonvulsants are being found
and studied each year.

Another useful form of treatment is the keto-
genic or high-fat diet. This is effective in child-
ren but not in adults.

Thanks to the work of neurosurgeons and,
particularly, to that of Dr. W. G. Penfield of the
Montreal Neurological Institute, surgical treat-
ment in carefully selected cases has become
more and more effective. This is particularly
true among adults but less so among young
children.

USE OF ANTICONVULSANT DRUGS

In the use of anticonvulsant drugs, the follow-
ing points must be kept in mind:

1. Treatment should be started as soon as the
diagnosis has been established, and the drug
that is most likely to be effective should be
selected. For example, trimethadione (Tridione)
is the drug of choice for petit mal seizures.

2. A small or moderate-sized dose of the drug
should be given at first and increased until at-
tacks are controlled or until signs of toxicity,
such as rash or ataxia, appear.

3. If one drug does not control the attacks,
one or more other drugs may be added. Again,
the dose should be increased until control is
gained or signs of toxicity appear.

4. Administration of anticonvulsant drugs
should be continued after attacks have ceased
for a minimum of two years and preferably
three to five years. The dose may then be re-
duced gradually over a period of a year or more.

haddow m. keith is a member of the Section of Pedi-
atrics at the Mayo Clinic and professor of pediatrics
in the Mayo Foundation.

If seizures recur, the dose must again be in-
creased immediately.

5. As with the administration of all drugs, the
patient must be observed frequently for signs of
toxic effects, such as vomiting, rash, ataxia, and
other less common signs. When drugs such
as trimethadione (Tridione), paramethadione
(Paradione), 5-ethyl-3-methyl-5-phenylhydantoin
(Mesantoin), and phenacemide (Phenurone) are
being given, the physician should be alert for
blood dyscrasia as well as for rash.

Anticonvulsant drugs in common use are listed
with the dosage in table 1.

Bromides were first used approximately one
hundred years ago in the treatment of epilepsy.
Although other drugs have been developed,
bromides remain among the more effective anti-
convulsants. They are usually prescribed as
triple bromides.

Phenobarbital, introduced by Hauptmann in
1912, is an effective anticonvulsant of low tox-
icity. It is probably used today more commonly
than any other anticonvulsant drug. A modifi-
cation of this substance, mephobarbital ( Meba-
ral) was introduced in 1932 and another bar-
biturate, metharbital (Gemonil), in 1950. Both
are fairly effective anticonvulsants of relatively
low toxicity.

Another group of drugs, the hvdantoins, are
useful. Diphenylhydantoin (Dilantin Sodium)
was discovered in 1938 by Merritt and Putnam,1
as a result of testing a large number of drugs for
their effect in controlling electrically produced
convulsions. This anticonvulsant has proved to
be relatively effective, especially in controlling
grand mal seizures, and it is almost as widely
used as phenobarbital. However, it causes more
side reactions. A similar hvdantoin, 5-ethyl-3-
methyl-5-phenylhydantoin (Mesantoin), is used
in the same way as Dilantin, but it tends to cause
more serious toxic reactions and must be used
with caution and with the patient under close
observation. More recently, another hvdantoin,
3-ethyl-5-phenvlhydantoin (Peganone), has been

NOVEMBER 1958

461

TABLE ]

ANTICONVULSANT DRUGS

Drug

Initial dose

Preferred in:

T oxic effects

Bromides

0.3

gm.

Grand mal

Drowsiness, acneform eruptions

Barbiturates

Phenobarbital

16

mg.

Grand mal

Drowsiness, irritability, rash

Mebaral

32

mg.

Grand mal

Drowsiness, irritability, rash

Gemonil

32

mg.

Grand mal

Drowsiness, irritability, rash

I tydantoins

Dilantin

32

mg.

Grand mal; mixed
grand and petit mal

Ataxia, diplopia, nystagmus, rash, nausea,
vomiting, gingival hypertrophy

Mesantoin

Sueeinimides

50

mg.

Grand mal; mixed
grand and petit mal

Drowsiness, rash, pancytopenia,
agranulocytosis

Milontin

0.5

gm.

Petit mal

Drowsiness, vertigo, hematuria, rash,
ataxia

Celontin

0.5

gm.

Petit mal; mixed
grand and petit mal

Drowsiness, vertigo, hematuria, rash,
ataxia

Others

Trimethadione ( Tridione)

0.15

gm.

Petit mal; akinetic and
myoclonic seizures

Photophobia, rash, agranulocytosis

Paradione

0.15

gm.

Petit mal; akinetic and
myoclonic seizures

Photophobia, rash, agranulocytosis

Mysoline

0.125

gm.

Grand mal; focal
motor seizures

Drowsiness, dizziness, ataxia, rash

Phenurone

0.5

gm.

Grand mal;
psychomotor

Rash, hepatitis, pancytopenia,
leukopenia, personality disturbance

Benzedrine

2.5

mg.

Petit mal

Irritability, restlessness, insomnia

Dexedrine

2.5

mg.

Petit mal

Irritability, restlessness, insomnia

Diamox

0.125

gm.

Petit mal

Rash, bone marrow injury

Meprobamate

0.1

gm.

Petit mal

Drowsiness, aggravation of grand mal

seizures

placed on the market. It is proving helpful in
various types of convulsive disorders in child-
ren, but it lias not been in use long enough to
be certain of its permanent value.

Trimethadione (Tridione) and paramethadione
(Paradione), discovered in 1945 and 1949, have
been of great value in treating patients with
petit mal seizures as well as those with akinetic
and myoclonic attacks. Both drugs occasionally
cause serious skin or other toxic reactions and
must be used cautiously. They also may pre-
dispose patients toward major seizures, but they
can be used in combination with the barbitu-
rates.

In 1951, Zimmerman2 reported the use of phen-
suximide ( Milontin ) to control petit mal at-
tacks. This has not proved as effective as was
hoped, but a similar substance, methsuximide
(Celontin), has been used recently with more

satisfactory results. Side effects have been noted
with both drugs: namely, dizziness, rash, drow-
siness, ataxia, and other more minor symptoms.
In a few cases, toxic effects necessitated with-
drawal of the drug.

Phenacemide (Phenurone) has been reported
to have completely controlled convulsive attacks
in 23 per cent of a small group of children.3
Livingston and Kajdi4 reported on a group of
104 patients treated with this drug and found
that it was effective only in psvchomotor epi-
lepsy. It tends to cause unfavorable side effects,
such as rash, personality disturbances, and, oc-
casionally, disturbances of liver function. It
must be used with caution, but children seem to
tolerate it better than adults.

Primidone, 5-phenvl-5-ethvlhexahydropyrimi-
dine-4,6-dione (Mysoline), has been shown to
control both generalized convulsions and auto-

462

THE JOURNAL-LANCET

matisms. In one series of cases, it controlled the
attacks in 57 per cent of patients who had not
been previously treated. In the beginning, child-
ren are given small doses, which are rapidly in-
creased to tolerance or the desirable therapeutic
effect.

Amphetamine sulfate (Benzedrine) and dex-
tro-amphetamine sulfate (Dexedrine) were re-
commended by Livingston5 for petit mal, but
they have not been as satisfactory as the diones.

Acetazolamide (Diamox), a derivative of the
sulfonamide drugs, acts as an inhibitor of car-
bonic anhydrase. It has been found to reduce
the frequency of seizures, mainly the petit mal
attacks but also, in some cases, the major con-
vulsions and the attacks in those patients with
spike and wave discharges appearing in their
electroencephalograms. Its beneficial effect seems
to last only a few weeks in many cases, that is,
a tolerance develops which prevents its anti-
convulsant action. Minor side reactions occur
but major toxic effects do not.

Meprobamate is a relatively new anticonvul-
sant drug, and patients with petit mal have been
reported as benefited by its use. Its action ap-
pears to be slower and less certain than that of
Tridione. No definite toxic effects have been ob-
served, but it has been reported that it aggra-
vates grand mal attacks.

KETOGENIC DIET

This diet is of considerable value in treating
children. It is thought difficult to administer,
but my colleagues and I have found that child-
ren take the meals well and that the diet can be
readily worked out with the help of a dietitian,
so that mothers can quickly learn how to pre-
pare the food.

To be effective, a ketogenic diet must be
rigidly controlled and should be weighed. It is
necessary that the ratio of the ketogenic material
to the antiketogenic material be at least 3:1.
This ratio is calculated according to Wood-
yatt’s formula in the following manner:

Ketogenic material — 90 per cent of fat

46 per cent of protein

Antiketogenic material — All of carbohydrate

58 per cent of protein
10 per cent ol fat

Therefore:

Ketogenic (or fatty acid) 0.90F + 0.46P

Antiketogenic (glucose) C + 0.10F + 0.58P

The diet is calculated for the individual pa-
tient as follows: The number of calories allowed
is 55 per kilogram or 25 per pound of body-
weight. The amount of protein is set at 1 gm.

TABLE 2

PLAN FOR BEGINNING USE OF KETOGENIC DIET
BY 8-YEAR-OLD BOY

Weight: 55 II). (25 kg.)

Calories: 1,375

25 calories per lb. (55 cal. per kg.) of body weight

Day of
diet

Carbohydrate,

gm.

Protein ,
gm.

Fat,

gm.

Calories

tin tin:
K/AK°

1st

50

25

119

1,371

1.5

2nd

35

25

126

1,374

2

3rd

20

25

133

1,377

2.7

4 th

15

25

135

1,375

3.1

'Ratio of

ketogenic to antiketogenic

material.

per kilogram of body weight, which has been
found to be satisfactory. The carbohydrate and
the fat are then adjusted so that the ratio is as
indicated, and the calories are satisfactory for
nutrition and growth. The caloric requirement
is based on the estimated weight for height, as
given in standard tables.

When the diet is begun, the amount of car-
bohydrate taken is decreased, and the amount
of fat is increased over a period of four days
(table 2). This gradual change is advisable be-
cause most children who are immediately given
the full diet become nauseated and sometimes
vomit severely. However, this very seldom oc-
curs with the indicated plan.

In order to make certain that the patient is in
a state of ketosis, a test for diacetic acid is made
on the first specimen of urine passed each morn-
ing. The patient’s mother can be taught to do
this readily. Patients must be kept on this diet
and in ketosis for six to twelve months. The
carbohydrate in the diet is then graduallv in-
creased, and the amount of fat is reduced until
the diet is essentially normal again, which us-
ually takes three to twelve months.

SURGICAL MEASURES

Surgical treatment has been shown to be effec-
tive in certain well-chosen cases. In the exten-
sive work done by Penfield and Jasper,6 pa-
tients were reported in 3 groups: (1) those

who underwent operations from 1929 to 1939;
( 2 ) those who were treated surgically from 1939
to 1944, inclusive; and (3) those operated on for
seizures caused by lesions of the temporal lobe
from 1939 to 1949, inclusive. Patients of the first
group were traced for one to eleven years, and,
in 43 per cent, treatment was successful. That
is, they had had no seizures after operation, or
they had had 1 or 2 attacks and then cessation
of seizures after operation. Patients of the sec-
ond group were traced for one to seven years,

NOVEMBER 1958

463

and, in 56 per cent, treatment was successful.
Patients of the third group were traced for one
to eleven years, and, in 53 per cent, surgical
treatment was considered successful.

RESULTS OF TREATMENT

The patient with recurring convulsions is in-
terested in complete and permanent control of
his attacks, and there are few reports of this
having been accomplished over long periods of
time. In a study of the use of bromides. Turner7
stated that attacks of 23.5 per cent of 366 pa-
tients were arrested for two and one-half to
twenty-two years. Arieff,8 in 1951, reported ob-
servations in the treatment of 543 patients, in-
dicating that in 61 per cent of his cases remis-
sions of six months to ten years were produced
by the use of triple bromides, phenobarbital, or
the two drugs combined.

Yahr and associates9 reported studies on 319
patients. With the use of Dilantin and pheno-
barbital, the attacks of 79 per cent were con-
trolled or decreased. The patients whose attacks
were considered controlled were those who were
free of seizures for less than six months up to
five and one-half years. The improved patients
were those whose seizures were reduced at least
50 per cent.

Of 190 patients treated by the ketogenic diet
whose cases I have studied, 35.3 per cent re-
mained entirely free of attacks for four to twenty-
two years, although treatment actually lasted

only one to three years, and another 8.4 per cent
improved. The 190 patients had grand mal,
petit mal, or both types of seizures.

From these published results, it seems en-
couraging that complete control of convulsive
attacks can be obtained in 23.5 to 35.3 per cent
of cases for as long as twenty-two years, and,
of course, the seizures of many more patients are
completely controlled for shorter periods. Surgi-
cal treatment may control episodes in as many
as 56 per cent of specially selected cases. In
addition, many patients are greatly helped by
these forms of treatment, although their convul-
sive attacks may not be entirely eliminated.

REFERENCES

1. Merritt, H. H., and Putnam, T. J.: Sodium diphenyl hy-

dantoinate in the treatment of convulsive disorders. J.A.M.A.
111:1068, 1938.

2. Zimmerman, F. T. : Use of methylphenylsuccinimide in treat-
ment of petit mal epilepsv. A.M.A. Arch Neurol. & Psychiat.
66:156, 1951.

3. Keith, H. M.: Use of Phenurone for convulsive disorders of
children. Am. J. Dis. Child. 80:719, 1950.

4. Livingston, S., and Kajdi, L.: Use of phenurone in treat-
ment of epilepsy. J. Pediat. 36:159, 1950.

5. Livingston, S.: The Diagnosis and Treatment of Convulsive
Disorders in Children. Springfield, Illinois: Charles C Thomas.
1954, p 195.

6. Penfield, W., and Jasper, H.: Epilepsy and the Functional
Anatomy of the Human Brain. Boston: Little, Brown and
Company, 19.54, p. 664.

7. Turner, W. A.: Epilepsy: A Study of the Idiopathic Disease.
London: Macmillan & Co., Ltd., 1907, p. 229.

8. Arieff, A. J.: Twelve-year resume in a clinic for epilepsy.

Dis. Nerv. System. 12:19, 1951.

9. Yahr, M. D., Sciarra, D., Carter, S., and Merritt, H. H.:
Evaluation of standard anticonvulsant therapy in 319 patients.
J.A.M.A. 150:663, 1952.

Low cerebrospinal fluid pressure is a sign of clinical significance in sev-
eral syndromes associated with cerebral hypotension. The normal range of
spinal fluid pressure in the lateral recumbent position is 70 to 180 mm. of water.

Cerebral hypotension after cranial trauma is probably caused by diminished
production of cerebrospinal fluid by the choroid plexus. The underlying cause
is a general decrease in cerebral circulation shown as disturbed consciousness.
Of 32 cases of cerebral hypotension, 14 followed trauma. The most prominent
symptom was headache, aggravated by the upright position. Symptoms were
frequently relieved by carbon dioxide inhalation.

A spontaneous variety of cerebral hypotension was seen in 3 patients. Al-
though carbon dioxide inhalation was temporarily helpful, headaches persisted
for several weeks, particularly when patients were in the upright position.
Vertigo was the chief symptom in 4 elderly patients, 2 with hypertension, in
whom reduced cerebrospinal fluid production was probably of reflex or direct
vasospastic origin. Decreased fluid pressure was apparently related to dimin-
ished cerebral circulation in 11 hypertensive or arteriosclerotic patients. Car-
bon dioxide inhalations were usually of great benefit.

Henry A. Shenkin, M.D., and Bernard E. Finneson, M.D., Albert Einstein Medical Center,
Philadelphia. Neurology 8:157, 1958.

464

THE JOURNAL-LANCET

Congenital Atresia of the Duodenum

Twenty-One-Year Interval Report

G. I. W. COTTAM, M.D., and VV.A. ARNESON, M.D.
Sioux Falls, South Dakota

This case was previously reported in March
1942,1 when the patient was 5 years old.
This article will cover the events in the next six-
teen years of this boy’s life.

Briefly summarizing the 1942 article, a gastro-
jejunostomy (figure 1) was done by G. I. W. C.
on a newborn, 5-lb., 11-oz. baby for an atresia
of the duodenum above the ampulla of Vater. In
addition, the infant was found to have a band
obstruction of the sigmoid which was clipped a
week later. He also had a spina bifida occulta
with short tendo achillis, a functional systolic
murmer at the apex of the heart, and an ortho-
static albuminuria. In the first eleven years of
his life after the surgery, his course was without
incident, and his development was normal for
a boy of his age. However, on and since De-
cember 28, 1948, he began to have periods of
upper gastrointestinal distress with accompany-
ing anemia, fainting spells, and occult blood in
the stools. This first hemorrhage followed a
blow in the epigastrium while scuffling with an
older boy. The hemoglobin fell to 56 per cent
or 8.65 gm. and the red blood count to 3,000,000.
He recovered completly on hematinics and medi-
cal management.

A year later, on January 11, 1949, he had a
similar episode of moderate upper gastrointesti-
nal bleeding which responded to blood tonics,
diet, and Pro-Banthine. He had no more gastro-
intestinal trouble for the next four years. Then
on October 26, 1953, and on January 3, 1954,
he bled quite severely and the hemoglobin fell
to 40 per cent or 5.75 gm. and the red blood
count to 3,060,000.

Surgical exploration was decided upon, and on
January 14, 1954, we carried out this procedure.
We found that the bleeding was coming from
the stoma and an ectopic piece of pancreas in the
anterior gastric wall. We also discovered that
the atresia was caused by annular pancreatic tis-
sue and scar (figure 2). The following surgical

c. i. w. cottam and w. a. arneson are specialists
in general surgery and maintain offices in Sioux
Falls.

Duodenum

Stomach

Large Posterior
G.E Opening

Jejunum, >rox

Fig. 1. First operation at birth showing large posterior
gastroenterostomy opening for adult life and obstructed
duodenum.

1st PORTION STOMACH

Fig. 2. Third operation, which was exploratory, dis-
closed the 2 blind ends of duodenum connected by a
solid cord covered by pancreatic and fibrous tissue. Ec-
topic pancreatic tumor in anterior stomach wall is also
shown.

corrective measures were used : ( 1 ) disconnec-
tion of the old gastrojejunostomy, (2) duodeno-
duoclenostomy, (3) excision of the ectopic pan-
creatic tumor, and (4) incidental appendectomy
(figure 3).

NOVEMBER 1958

465

Fig. 3. Third operation showing excision of ectopic
pancreas from stomach wall and duodenal anastomosis
after old gastrojejunostomy was disconnected.

It has been over four and one-half years since
the above surgical procedures were done, and
the patient has been well ever since. We believe
that he will have no more trouble.

In retrospect, we admit that some other type
of short-circuit operation2 might have produced
better results than the gastrojejunostomy. Many
surgeons prefer jejunoduodenostomy or duodeno-
duodenostomy. In this case, with the baby in
poor condition, we selected the quickest and
easiest method, and it is fortunate that we did,
because, sooner or later, re-operation for the

ectopic pancreas would have become necessary.
In the meantime, he has developed normally.

SUMMARY

We have presented an interval report on a
twenty-one year follow-up of a patient with 7
congenital anomalies: (1) atresia of the duo-
denum, (2) annular pancreas, (3) ectopic pan-
creas, (4) spina bifida occulta, (5) short tendo-
achillis, (6) functional heart murmur, and (7)
orthostatic albuminuria. The anomalies of the
gastrointestinal tract necessitated 3 separate
surgical procedures. The other anomalies re-
sponded to medical and expectant treatment.

The final result is a normal, healthy 21-year-
old young man who has just completed his pre-
medic years with an average of A—. This fall,
he will begin his first year of medicine. Except
for his gastrointestinal tract, none of the anom-
alies has caused him any physical disability.
As a youngster, the short tendo achillis caused
him to walk on his toes for two years. Now he
walks normally and runs the hundred-yard dash
in eleven seconds. He actively competes in all
forms of athletics.

REFERENCES

1. Cottam, G. I. W., and Cottam, Gilbert: Congenital atre-
sia of the duodenum. Journal-Lancet 62:83, 1942.

2. Arneson, W. A., and Ihle, C. W., Jr.: Congenital intrinsic
obstruction of the duodenum. Ann. Surg. 139:95, 1954.

In patients with congenital malformations of the heart who survive
intrapericardial operations, a syndrome identical to the postcommissurotomy
syndrome may be seen.

The syndrome occurs after transventricular and transarterial valvuloplasty
for pulmonary stenosis, closure of septal defects, and exploration of the peri-
cardium for inoperable congenital cardiac lesions. Although other factors may
be important pathogenetically, the feature common to these operations in the
nonrheumatic as well as the rheumatic patient is wide incision of the pericar-
dium, with or without cardiotomy or valvotomy. The complication is not noted
after operations wherein the pericardium is not disturbed or a small segment
of pericardium is clamped to remove a cyst.

The term postpericardiotomy syndrome is suggested as being more ap-
plicable than postcommissurotomy syndrome. The syndrome is interpreted as
traumatic pericarditis and may be a reaction to blood in the pericardial sac.
This postoperative manifestation in nonrheumatic patients is a compelling argu-
ment against the theory that the syndrome in patients who have had mitral
valvotomy usually represents reactivation of rheumatic fever.

Tomiko Ito, M.D., Mary A. Engle, M.D., and Henry P. Goldberg, M.D., New York Hospital-
Cornell Medical Center, New York City. Circulation 17:549, 1958.

466

THE JOURNAL-LANCET

Injuries of the Urinary Tract

HERBERT E. LANDES, M.D., and EDWARD T. WILSON, M.D.
Chicago, Illinois

The alarming and mounting accident rate
associated with increasing high speed trans-
portation, vast industrialization, and increased
participation in strenuous sports makes trauma
a subject of ever increasing importance to the
civilian practitioner of medicine.

KIDNEY INJURIES

Kidney injuries account for about one-fourth of
one per cent of all hospital surgical admissions.
Since the kidneys are soft, pulp-like organs al-
ways distended with blood and easily torn, they
would be injured very often except for their
protected location. The rigid spine, the lumbar
muscles, the lower ribs, the cushion of perirenal
fat, and the mobile attachments of the kidneys
greatly reduce the incidence of trauma. The right
kidney is injured more often than the left, prob-
ably because its intimate contact with the under
surface of the liver reduces its mobility. Kidney
injuries are slightly more common in children.

Wounds of the kidney are of 2 types. Pene-
trating wounds common in war are seen occa-
sionally in civilian practice. They are the re-
sult of bullet wounds or other piercing objects
brought into violent contact with the body.
Much more common are the injuries resulting
from direct force applied to the upper abdomen,
loin, or costovertebral angle or by falls terminat-
ing in a severe blow to the kidney area. Falls
on the buttocks, feet, or head may tear the kid-
ney from its vascular pedicle. A rare tvpe of
kidney injury, of which the author has seen 1
case, resulted from sudden, violent twisting of
the lumbar spine while lifting a heavy object.

Davis has shown that the soft, blood-distended
kidney responds to a blow like a paper sack

Herbert e. Landes is professor ' and chairman of the
Department of Urology, Stritch School of Medicine
of Loyola University and chairman of the Depart-
ment of Urology , Mercy Hospital, Chicago, edward
t. wilson is assistant professor of urology, Stritch
School of Medicine and senior attending urologist,
Mercy Hospital.

Paper presented at the annual meeting of the
North Dakota State Medical Association in Minot,
May 1958.

filled with water. Since the force is transmitted
in all directions, the kidney may be fragmented
by many fractures. Severe crushing injuries may
result in kidney damage, though the kidney in-
jury may be of minor importance compared to
trauma to the abdominal viscera. Diseased kid-
neys, especially those with a hydronephrotic sac
or large polycystic kidneys, are more susceptible
to injury.

The degree of injury ranges from a slight tear
of the capsule with superficial Assuring of the
parenchyma to complete fragmentation and de-
struction of the kidney’s internal architecture.
Also, the vascular pedicle may be involved with
subsequent infarction of much of the kidney.

Shock of varying degree occurs in all cases of
severe injury, although it may be delayed a few
hours, particularly in children.

Pain in the hypochondrium, loin, or costoverte-
bral angle is a constant symptom. Tenderness
over the kidney in the back, as demonstrated by
gentle fist percussion, is almost pathognomonic
for lesions in or around the kidney. Tenderness
in the upper abdomen and loin is pronounced.
Associated muscle spasm may prevent deep pal-
pation of the kidney region. Later, when rigidity
is less marked, a large mass composed of blood
and blood clots confined within Gerota’s capsule
may be palpated. Reflex peritoneal irritation and
abdominal distention with or without nausea
and vomiting are delayed symptoms. Symptoms
of generalized peritonitis occur with hemorrhage
into the free peritoneal cavity.

Blood occurs in the urine in 90 per cent of
kidney injuries. It varies from a few red cells
to a profuse, gross hematuria of sufficient degree
to exsanguinate the patient. It may be absent
occasionally if the ureter has been completely di-
vided or is completely closed with blood clots.

Chills and fever denote the onset of infection
secondary to urinary extravasation into the peri-
renal tissues or to spontaneous infection of large
masses of extravasated blood.

The history is of value in evaluating the type
of injury. With the exception of patients suffer-
ing from severe shock, most patients with kidney
trauma are in sufficiently good condition to per-
mit physical examination.

NOVEMBER 1958

467

External abrasions, contusions, or puncture
wounds in the kidney region suggest kidney in-
jury, but, in many cases, they are absent. The
general picture of shock is easy to recognize, and
the pulse rate, blood pressure, and blood count
indicate its degree. Immediate urinalysis of
either a voided or catheterized specimen is indi-
cated. Physical examination gives a rough idea
of the extent and direction of the renal hemor-
rhage.

The type and extent of the kidney injury is
next determined by secretory urography, which
produces satisfactory results in about 40 per cent
of cases. If shock or severe kidney damage in-
terferes with visualization by intravenous meth-
ods, cystoscopy and retrograde pyelography
should be done at once. These procedures will
denote any disturbance in the internal architec-
ture of the kidney or extravasation into the peri-
renal tissues. Treatment is predicated on the
basis of an accurate knowledge of the type and
extent of the injury. This knowledge can be ob-
tained only by these methods. They likewise es-
tablish the presence and condition of the unin-
jured kidney. This is, of course, of paramount
importance when removal of the injured kidney
is contemplated. Finally, roentgen studies of the
kidney, ureter, and bladder tract reveal the kid-
ney outlines, the psoas shadows, and the bony
structures of the spine and pelvis.

TREATMENT OF KIDNEY INJURIES

The treatment of kidney injuries is either con-
servative or surgical, depending on the degree
of injury and the associated hemorrhage. The
indications for surgical intervention are contro-
versial; surgeons of fairly equally large experi-
ence hold divergent views. The advocates of sur-
gery, in most cases, point to the late effects of
renal trauma, such as hydronephrosis, calculus,
calcified cysts, and compression atrophy causing
the Goldblatt type of hypertension. They infer
that early surgical intervention would have pre-
vented many of these sequelae.

The advocates of conservative treatment cite
excellent results with equally large series of
cases in which only 10 to 15 per cent of the pa-
tients were subjected to surgical treatment. Since
the type of injury varies from a slight laceration
of the parenchyma to complete fragmentation of
the entire organ, the treatment varies with the
degree of injury and the extent of the associated
hemorrhage.

Minor injuries associated with slight or tran-
sient hematuria, slight pain in the kidney region,
minimal physical findings, and fairly normal se-
cretory or retrograde pyelograms may be treated

by hospitalization, absolute rest in bed, ice bags
applied to the kidney region or external heat to
the body, if indicated, and drugs to relieve pain
or restlessness. Chemotherapy should be started
at once in all cases. Periodic physical examina-
tions, blood pressure, pulse rate, blood count,
and urinalysis aid in following the progress of
the case. Absolute rest in bed for two to three
weeks is indicated. Hematuria should be absent
for at least a week before the patient is allowed
out of bed. Too early resumption of activity may
precipitate a secondary hemorrhage. Pyelograms
should be made in three to six months after dis-
charge and compared with the originals.

The more severe injuries associated with shock,
continued severe or recurrent bleeding, urinary
suppression, or the symptoms of sepsis require
surgical intervention. The surgical measures con-
sist of control of the bleeding, removal of blood
clots, suture of the injured kidney, if feasible,
and provision for drainage. Rapid nephrectomy
may be required if the bleeding cannot be con-
trolled by suture or pack or if the kidney’s blood
supply lias been severely damaged. The usual
measures for recognizing and treating surgical
shock either before, during, or after surgery are
indicated, and surgical judgment is of paramount
importance in treating these critical cases.

The prognosis in minor injuries is excellent.
The mortality in severe renal injuries is about 30
per cent, although this figure can be greatly re-
duced when adequate facilities for prompt, ac-
curate diagnosis and treatment are available.

Wounds to the ureter are rare except those
occurring during various surgical procedures.
While this is an important subject, time does not
permit a discussion of it here.

Traumatic injuries to the urethra and bladder
are of great surgical importance, because the life
or future comfort of the patient often hinges
upon the accurate diagnosis and prompt surgical
treatment of these lesions. While comparatively
infrequent due to the installation of safety de-
vices by railroads and manufacturers, they are
not uncommon results of automobile accidents,
so-called straddle injuries in which the urethra
is crushed against the pelvic bones, kicks or
blows on the perineum, and numerous mishaps
of the alcoholic who manages to fall upon a dis-
tended bladder. They are often associated with
pelvic fractures and disruption of the pelvic ring.

A relatively small percentage of the total num-
ber of these injuries are encountered by tbe uro-
logic surgeon. Most of them are surgical emer-
gencies which are seen and treated by the gen-
eral practitioner or which are referred by him
to the general surgeon.

468

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URETHRAL INJURIES

Urethral injuries are classified according to the
degree of tearing as: (1) interstitial, in which
the mucosa is intact, (2) partial rupture, in
which the wound is a rent involving all layers of
the urethra, and (3) complete rupture, in which
the urethra is completely divided, probably with
pronounced retraction of the torn ends.

These grades of injury cannot always be defi-
nitely established clinically. However, whenever
the history of an injury commonly producing
urethral trauma is associated with urinary reten-
tion, urethral bleeding, pain, and perineal hema-
toma, prompt surgical intervention is always in-
dicated.

Ruptures of the pendulous urethra are rare and
generally occur as a complication of a so-called
fracture of the erect penis. Hemorrhage at the
meatus, which may be profuse, does not neces-
sarily indicate the extent of the injury. Marked
tumefaction of the periurethral tissues caused by
hemorrhage produces intense pain and rapidly
increasing urinary difficulty. Diversion of the
urinary stream by perineal urethrotomy or supra-
pubic cystostomy is the operation of choice.
Many of these cases have been successfully
treated immediately by retention catheter, as
advocated by Haines, but the use of the catheter
predisposes to infection, fistula formation, and
urethral stricture.

In recognizing and treating injuries of the
urethra proximal to the pendulous portion, a
few fundamental points concerning the anatomy
of the perirenal fasciae and urethra are essential.

Unless these fascial layers are ruptured at the
time of the injury, they so completely limit the
extent of blood and urinary extravasation that
the exact location and degree of injury can be
determined at the first examination.

Urine or blood entering the perineal tissues
distal to the intact triangular ligament is con-
fined superficially by Codes’ fascia and prevented
from extending backward by the inferior layer
of the triangular ligament. Being limited laterally
by the attachment of Colies’ fascia to the ischio-
pubic rami, it first distends the loose tissues of
the scrotum and perineum and then extends up
along the spermatic cord to the lower abdomen.
The close attachment of Colies’ fascia to Buck’s
fascia, which encloses the erectile bodies and the
urethra, prevents early tumefaction of the penis,
but, once the extravasation has reached the su-
perficial abdominal layers, it may then extend
down over the pubes to the superficial layers of
the penis. The close attachment of Scaqia’s
fascia to Poupart’s ligaments prevents descent to
the thighs.

Injuries of the urethra at the triangular liga-
ment or at the apex of the prostate, in which the
inferior layer of the ligament remains intact,
lead to tumefaction in the tissues around the
prostate often with upward displacement of this
structure, to boggy swellings in the ischiorectal
fossae, and to distention of the space of Retzius
with blood and urine.

In severe crushing injuries associated with pel-
vic fracture, the fascial layers may be injured so
that both types of extravasation occur. In such
cases, the bladder as well as the urethra may be
torn or lacerated.

Ruptures of the bulbous urethra are commonly
the result of straddle injuries or a kick or blow
in the perineum, which crushes the urethra be-
tween the injuring body and the pubic arch.
The extent and location of the injury are deter-
mined by the direction as well as the degree of
the injuring force.

The symptoms and findings are severe pain,
urinary frequency, or strangury with the passage
of very blood-tinged urine or pure blood together
with rapidly ensuing acute retention. Bleeding
at the meatus is generally present, although, in
severe injuries, it may be slight. Extensive tume-
faction of the perineal tissues always indicates
severe injury. When urinary extravasation occurs,
it is limited by Colles’ fascia. Diagnostic instru-
ments usually find an impassable obstruction in
the bulb if the rupture is complete. The strictest
aseptic precautions should be observed in all
diagnostic instrumentation, and a soft rubber
catheter is less dangerous than a rigid instru-
ment. Incomplete rupture is generally patulous
to the catheter; complete rupture seldom is.

TREATMENT OF URETHRAL INJURIES

The treatment of all ruptures of the urethra in-
volves a consideration of 3 points : ( 1 ) diversion
of the urinary stream away from the injured
urethra, (2) anatomic reconstruction of the in-
jured urethra, and (3) treatment of stricture
which generally follows all severe urethral in-
juries.

Diversion of the urinary stream away from the
injured urethra. The merits of the individual case
determine whether this is best done bv retention
catheter, perineal urethrotomy, or suprapubic
cystostomy. A retention catheter increases the
possibility of infection, fistula, and stricture, but
many ruptures of the pendulous urethra can be
successfully treated by this simple method.
Perineal urethrotomy is probably the operation
of choice in partial ruptures of the deep urethra
when the urethra is patent to instruments, be-
cause perineal section not only affords dependent

NOVEMBER 1958

469

drainage but permits suture of the urethral de-
fect as well. Drainage bv suprapubic cystostoinv
and retrograde instrumentation is the operation
of choice in most complete ruptures of the deep
urethra. This should be combined with perineal
section, evacuation of clots, and urethral repair
if the perineal hematoma is large or if urinary
extravasation has already begun. Retrograde
instruments greatly facilitate the location of the
proximal end of the urethra. The urethra can
then be closed by intramural sutures of fine cat-
gut over a catheter.

Anatomic reconstruction of the injured urethra.
Upon this point, there is considerable divergence
of opinion. It is often true that open operation
reveals a more severe injury and greater retrac-
tion of the ruptured ends of the urethra than
physical findings indicated. In such a case, one
feels certain that open operation and suture of
the urethra are imperative. But, it is likewise
true that if a patent channel is maintained be-
tween the divided ends of the urethra, the
mucous membrane has the intrinsic power of
covering large defects in which no suture is at-
tempted.

Many who favor the latter procedure can cite
numerous severe urethral injuries that have been
treated simply bv cystostomy and retrograde in-
strumentation with no attempt at urethral repair
by perineal section. Yet, one cannot escape the
feeling that anatomic reconstruction by suture
of the urethra is a better surgical principle.

Treatment of stricture which follows almost
all severe urethral injuries. Instrumentation
should be begun after about fourteen days and
continued at regular intervals for at least a year.
When the retention catheter is removed after
ten to fourteen days, it should be replaced im-
mediately by a filiform designed to screw to a
follower. By serving as a guide, tin's permits
easy dilatation with the minimum amount of
trauma at the site of the injury. The filiform
is worn constantly for the next two or three
weeks, after which the urethra may be safely
instrumented with sounds. Regular dilatations
for a period of many months are necessary, be-
cause the urethra must be kept at normal caliber
at the site of the injury. The trauma of the uri-
nary stream impinging against a narrow place is
sufficient in itself to cause progressive contrac-
tion of the stricture area.

Rupture of the membranous urethra is most
often associated with fractures of the pelvic
bones and is always a most serious and not infre-
quently fatal injury. Disruption of the pelvic
ring not only tears the urethra and both layers
of the triangular ligament but often causes lac-

eration or rupture of the bladder and injury to
other viscera.

Such cases tax the judgment of the surgeon.
Blood transfusion and other supportive methods
are often required before any surgery can be
considered; yet, to wait many hours greatly in-
creases the mortality.

Diversion of the urinary stream by suprapubic
evstostomy protects the crushed urethral and
perineal tissues from the dangers of urinary ex-
travasation and also enables one to inspect the
interior of the bladder for laceration or rupture.
Retrograde instrumentation by paired sounds is a
great aid in passing a retention catheter through
the ruptured urethra. The catheter splints the
urethra and tends to correct any deformity from
possible rupture or laceration of the pubopros-
tatic ligaments in addition to maintaining con-
tinuity and assisting in drainage. Perineal sec-
tion and evacuation of blood clots are not im-
perative procedures but should be done if frac-
tures do not make the lithotomy position dan-
gerous or impossible. Occasionally, secondary
repair of the urethra with closure of urinary fis-
tula may be required.

Uncomplicated rupture of the posterior urethra
is quite rare and generally results from instru-
mental trauma. Drainage by retention catheter
is the treatment of choice, and, if the catheter
is placed before urinary extravasation or infec-
tion develops, these injuries are usually not very
serious. The posterior urethra, especially the
prostatic portion, shows little tendency to sub-
sequent stricture formation.

BLADDER INJURIES

Rupture of the bladder occurs about as often
as rupture of other abdominal organs. It prob-
ably never occurs spontaneously in a normal
bladder no matter how great the distention.
With the exception of puncture wounds or tears,
such as occur from bone fragments in pelvic
fracture, gun shot wounds, or stab wounds, it
is generally a rent in the bladder resulting from
external violence applied over or near the dis-
tended organ. Even a slight fall has been known
to rupture the greatly distended bladder, and
the injury may not be suspected until peritonitis
has developed.

Ruptures of the bladder may be either intra-
peritoneal or extraperitoneal, and ruptures into
the peritoneal cavity are far more frequent as
well as more serious. Ruptures generally involve
the unsupported portions of the bladder wall
near the vault and are usually simple transverse
tears involving all layers of the bladder and its
peritoneal covering.

470

THE JOURNAL-LANCET

If the rupture is extraperitoneal, the tissues
are infiltrated with urine according to the loca-
tion of the injury. If it occurs on the anterior
wall, a prevesical tumefaction results. All extra-
vasations rapidly fill the loose tissues around the
bladder so that very soon both prevesical and
retroperitoneal accumulations are seen. The tri-
angular ligament prevents spread into the perine-
um, and rarely is there any spread to the ischio-
rectal fossae.

The symptoms of bladder rupture are some-
times marked by shock, but pain is a constant
feature. If the injury is intraperitoneal, the pain
is peritoneal in origin and is often associated
with distention, nausea, and vomiting. If extra-
peritoneal, the pain may be localized in the low-
er abdomen and may radiate to the perineum,
penis, and thighs. Desire to void is constant,
often amounting to strangury, and, unless the
rent is very small, only small amounts of bloody
urine can be passed. Fever occurs early and in-
creases as sepsis develops.

Uncomplicated rupture of the bladder is gen-
erally diagnosed easily, but when associated with
other injuries, particularly those of the urethra,
the diagnosis can often be made only at opera-
tion.

Signs of severe bladder irritation and the fail-
ure to pass urine indicate catheterization, which
should, of course, be done with aseptic precau-
tions. If the urethra is patulous, urethral rupture
is unlikely. If the rupture is large, a very small
quantity of blood-stained urine is obtained. Or,
in some instances, the catheter may pass through
the rent into the abdominal cavitv drawing off a
large quantity of blood-stained urine from the
peritoneal cavitv. If the rupture is small, vary-
ing quantities of urine will be obtained, and the
diagnosis is more difficult.

An ingenious test has been proposed by
Vaughan and Rudnick. A measured quantity ol
air (about 400 cc., the capacity of the average
bladder but less in young individuals) is intro-
duced through a catheter. The bladder may he
viewed during the injection through the Huoro-
scope, or a roentgenogram may be taken imme-
diately after the injection is completed. If the
bladder is intact, its outline is rounded and reg-
ular. If there is an extraperitoneal rupture, air
is seen in the pelvic tissues or prevesical space.
If the rupture is intraperitoneal, the air appears
in the anterior part of the peritoneal cavity above
the intestines, and the bladder is partially or
entirely collapsed. This appears to be a reliable
test, but, as in all other procedures that necessi-
tate putting something into the bladder, it should
be followed immediately by operation if rupture
is demonstrated.

Often the diagnosis cannot be made with cer-
tainty until exploratory operation has been done.

TREATMENT OF BLADDER INJURIES

The treatment is operative in all cases, and the
prognosis depends upon the promptness of op-
erative interference. Unless operated upon, all
intraperitoneal ruptures of the bladder are fatal
in seven to fourteen days.

The bladder is exposed through a midline
suprapubic incision. It is preferable to open the
peritoneal cavity and carefully explore the peri-
toneal surface of the bladder before opening the
bladder cavity; otherwise, small intraperitoneal
injuries may be overlooked.

Extraperitoneal injuries are less serious but re-
quire prompt suprapubic cystostomy and free
drainage of the space around the bladder. If
the patient is operated upon early, the prognosis
is excellent.

NOVEMBER 1958

471

Curable Hypertension

RAY W. GIFFORD, JR., M.D.
Rochester, Minnesota

Although the medical treatment of hyper-
tension is rather effective, it is fraught with
many unpleasant and, at times, dangerous side
reactions. It is expensive, time-consuming, and
tedious; and it is only palliative. Cessation of
treatment is followed promptly by resumption of
hypertension in most cases.

For these reasons, the physician who un-
dertakes the treatment of hypertensive patients
should conduct a diligent search for the causes
of hypertension that are potentially amenable to
cure by appropriate surgical attack. These in-
clude coarctation of the aorta, tumors of the
adrenal medulla ( pheochromocytoma ), tumors
or hyperplasia of the adrenal cortex ( Gushing’s
syndrome and primary aldosteronism), unilat-
eral disease of the renal parenchyma ( atrophic
pyelonephritis, hydronephrosis, and renal tuber-
culosis), and occlusive disease of one or both
renal arteries or their branches.

Imperative for the diagnosis of these condi-
tions are clinical acumen, a high index of suspi-
cion, a carefully elicited history, a carefully per-
formed physical examination, and a certain com-
pulsion about routinely subjecting hypertensive
patients to special laboratory investigations, for
some of these causes of secondary hypertension
may be discovered more by chance than by sa-
gacity.

Clues that hypertension may be secondary and
not primary include: (1) recent or sudden onset
of hypertension, especially if the family history
is negative for hypertensive disease; ( 2 ) hyper-
tension in persons less than 30 years of age and
especially in children; (3) the appearance of
hypertensive retinopathy of group 3 or 4 soon
after the onset of hypertension; and (4) severe
hypertensive retinopathy with minimal or no
sclerosis of the retinal arterioles.

Having made these generalizations, I hasten
to add that secondary hypertension can be mild
and unaccompanied by severe grades of reti-

ray w. gifford, jR., is affiliated with the Section of
Medicine at the Mayo Clinic.

Paper presented at the annual meeting of the
North Dakota State Medical Association at Minot,
May 1958.

nopathy. It can occur in old as well as young
patients, and long duration of hypertension does
not rule out secondary hypertension, but it does
lessen the chances that operation will effect per-
manent reduction in blood pressure.

Not pertinent to this discussion are those types
of secondary hypertension which are not amena-
ble to surgical treatment and potential cure.
These conditions include bilateral renal disease,
such as polycystic kidneys and acute and chronic
nephritis.

COARCTATION OF THE AORTA

When hypertension is encountered in children
or adolescents, coarctation of the aorta should
be suspected. I do not mean to imply that co-
arctation of the aorta should not be considered
in adult hypertensive patients, for some persons
with this condition may survive into the fifth
decade.

The history is of little value in making the
diagnosis, since coarctation of the aorta is usual-
ly an asymptomatic condition. Because of asso-
ciated murmurs in the cardiac region, the erro-
neous diagnosis of rheumatic fever is sometimes
made. Thus, any hypertensive child or adoles-
cent who has been told that he has a “rheumatic
heart” may well prove to have coarctation of the
aorta.

The diagnosis is usually made from findings
at physical examination and is confirmed bv
roentgenograms of the thorax. Unfortunately,
for us clinicians, the reverse order occasionally
obtains. Typical findings on examination are hy-
pertension in the upper extremities, usually of
mild degree; impalpable pulses in the abdominal
aorta and lower extremities; and thrills and bruits
over the posterior aspect of the rib cage due to
the enlarged and tortuous intercostal arteries
which serve as collateral vessels in transporting
blood around the coarcted region. A systolic
murmur may be heard along the left sternal
border and to the left of the spinal column in
the interscapular region of the back. Palpation
of the femoral pulses in the groin is the most im-
portant maneuver in the examination. Coarcta-
tion of the aorta is the only condition in a child
or adolescent that causes absence of femoral

472

THE JOURNAL-LANCET

pulses with little or no evidence of serious is-
chemia in the lower extremities. The presence
of femoral pulses does not always rule out this
anomaly, however, for if collateral circulation
is abundant, there may be pulsatile How in the
lower extremities. In such cases, though, the
pulses are usually diminished in amplitude, and
the blood pressure is lower in the legs than in
the arms.

When coarctation occurs proximal to or at the
origin of the left subclavian artery, pulses may
be absent or diminished in the left arm as well
as in the legs. If anomalous origin of the right
subclavian artery is distal to the coarctation,
a similar situation may exist in the right arm.
In rare but fascinating cases, in which there is
a right-to-left shunt through a patent ductus ar-
teriosus distal to coarctation of the aorta, cyano-
sis is confined to the lower half of the body.

Bicuspid aortic valve is associated with co-
arctation of the aorta in approximately a third
of cases and may give rise to the murmur of
aortic regurgitation.

Typical x-ray findings include absence or de-
creased prominence of the aortic nob and notch-
ing along the inferior margins of the ribs pos-
teriorly due to erosion by the dilated and tortu-
ous intercostal arteries. There may or may not
be evidence of cardiac enlargement with promi-
nence of the left ventricle.

Only rarely must one resort for diagnosis to
simultaneous direct blood pressure and pulse
wave contour studies from the radial and femoral
arteries. Angiocardiography and thoracic aortog-
raphy are sometimes helpful in determining the
extent of the coarctation but are not necessary
routinely. Surgical resection of the aorta is the
only effective treatment. End-to-end anastomo-
sis can usually be accomplished without inter-
position of a graft. Unless serious cardiac em-
barrassment occurs, most surgeons prefer to
defer surgery in children until the patient is
8 to 12 years of age.

ADRENAL TUMORS OR HYPERPLASIA

Medullary tumors. Pheochromocytomas are chro-
maffin tissue tumors which usually occur in the
adrenal medulla. These tumors secrete excessive
amounts of epinephrine and norepinephrine,
thereby causing paroxysmal or sustained hyper-
tension. In the past thirteen years at the Mayo
Clinic, the diagnosis of pheochromocytoma has
been made preoperativelv in more than 60 pa-
tients, all of whom had their tumors surgically
removed without operative mortality. The tu-
mors may be multiple and occur in chromaffin
tissue other than the adrenal medulla. In our

experience, they have been found along the
aorta, at the bifurcation of the aorta, and behind
the right lobe of the liver.

Approximately 50 per cent of the tumors seem
to secrete their pressor substances more or less
continuously, producing sustained hypertension
that may be easily confused with ordinary essen-
tial hypertension.1

Pheochromocytoma may occur at any age.
The history is often helpful in alerting the phy-
sician to the possibility of such tumors. Severe
and frequently paroxysmal headaches, excessive
sweating, tremors, palpitations, increasing nerv-
ousness, and loss of weight are valuable clues
to this diagnosis.

Even in patients with sustained or persistent
hypertension caused by pheochromocytoma, the
blood pressure tends to fluctuate widely, and
paroxysmal attacks of headache, sweating, and
tremulousness accompanied by pallor and exces-
sive hypertension (at times to more than 300
mm. of mercury systolic and 150 mm. diastolic)
may occur. Patients whose hypertension has re-
sponded paradoxically to medical treatment, es-
pecially to ganglion-blocking agents, should be
suspected of having pheochromocytoma. This is
also true of patients whose blood pressure rises
sharply during induction of anesthesia.

Patients with sustained hypertension caused
by pheochromocytoma are almost always thin.
Tachycardia is common. The tumor is rarely
palpable. Most of these patients have elevated
basal metabolic rates, some markedly so. In
fact, the highest basal metabolic rates ever re-
corded at the Mayo Clinic have been in patients
with such tumors. This hypermetabolism in ad-
dition to the symptoms and physical findings
often leads to mistaken diagnoses of hyperthy-
roidism. Fortunately, the protein-bound iodine
and radioiodine tracer studies yield normal find-
ings when hypermetabolism is caused by pheo-
chromocvtoma. About 50 per cent of patients
with hypertension secondary to pheochromocy-
toma have elevated levels of fasting blood sugar.
The triad of H’s, therefore, has come to be help-
ful diagnostically: (1) hypertension, (2) hyper-
metabolism without hyperthyroidism, and (3)
hyperglycemia.

Definite tests for pheochromocytoma are of
two types: pharmacologic and chemical. Phen-
tolamine (Regitine) is used most widely in the
pharmacologic test when hypertension is per-
sistent.2 After the patient has been at rest and
the basal blood pressure has been determined,
5 mg. of this drug is given intravenously. A drop,
usually within five minutes, of more than 40 mm.
of mercury systolic and 25 mm. diastolic from

NOVEMBER 1958

473

the basal levels is considered positive evidence
of a pheochromocytoma. Falsely positive resnlts
occur with disappointing frequency, especially
if adequate basal levels of blood pressure have
not been obtained or if the patient has received
sedation or is under the influence of antihyper-
tensive medication at the time the test is done.

More and more diagnostic reliance is being
placed on chemical determinations of plasma
pressor amines’ 8 or urinary catecholamines4 or
both. Such tests, if done properly, are accurate
but unfortunately are so complicated that thev
are not at present widelv available, whereas the
Regitine test can be carried out in the physician’s
office.

We feel that pharmacologic or chemical tests
for pheochromocytoma should be performed
more or less routinely for all hypertensive pa-
tients, since, in a few, the history and laboratory
findings fail to reveal whether a tumor is present.

Pharmacologic and chemical tests are not
always conclusive, and, at times, surgical explo-
ration may be indicated as a diagnostic as well
as therapeutic procedure. Unfortunately, excre-
tory urography more often than not fails to local-
ize the tumor, and retroperitoneal insufflation of
air is potentially hazardous. For these reasons
and because the tumors are sometimes multiple
and can occur in extra-adrenal sites, exploration
of the abdomen through a transverse upper ab-
dominal incision is the procedure of choice.1
Expert control of blood pressure during and
after the surgical procedure is mandatory. Regi-
tine is given to control the paroxysms of exces-
sive hypertension that characteristically occur
during induction of anesthesia and operative
manipulation of the tumor. Levarterenol (Levo-
phed) or metaraminol (Aramine) is needed to
combat hypotension during the first hours after
the tumor has been removed.

Surgical exploration is indicated not only in
an effort to alleviate the hypertension but also
because 10 per cent of pheochromocytomas are
malignant. Hypertension is regularly ameliorated
by removal of the tumors, although not all pa-
tients become normotensive.

Hyperplasia or tumors of the adrenal cortex
can produce two conditions to which hyperten-
sion may be secondary or associated.

1. Cushings syndrome:' Ninety per cent of pa-
tients with Cushing’s syndrome have hyperten-
sion. Although usually mild, it may be severe
and constitute the chief complaint. Eighty per
cent of patients with Cushing’s syndrome are
women, usually less than 50 years of age. It
rarely occurs in children.

The characteristic appearance of the patient

is the most important clue to diagnosis. Typical
is the round or moon facies with truncal obesity,
eervicodorsal hump, plethora, acne, hirsutism,
and purplish striae.

The history is helpful only in so far as it con-
firms a change in facies and body habitus; pre-
vious photographs of the patient are valuable in
this regard. The history may reveal such non-
specific complaints as weakness, amenorrhea, loss
of libido, and psychic changes. A history of dia-
betes in addition to other findings is suggestive,
since 80 per cent of the patients with Cushing’s
syndrome have»hyperglycemia. Patients in whom
this syndrome has led to severe osteoporosis and
spontaneous fractures or vertebral collapse may
reveal a history of bone pain.

Helpful laboratory data include lymphope-
nia, hyperglycemia, alkaline urine, hypokalemia,
alkalosis, polycythemia, and osteoporosis. The
most conclusive diagnostic test is the finding of
elevated levels of corticosteroids in the urine and
in the blood. The levels of 17-ketosteroids in
urine may be normal.

Cushing’s syndrome results from hvperfunc-
tioning of the adrenal cortex, which usually is
due to hyperplasia but sometimes to tumors.
The treatment is surgical and consists of remov-
ing the adrenal cortical adenoma or carcinoma,
if present, or total or subtotal adrenalectomy if
hyperplasia is responsible. In most cases, the
clinical features and hypertension regress after
appropriate surgery.

2. Primary aldosteronism. Certain tumors of the
adrenal cortex produce hypertension by secret-
ing excessive amounts of aldosterone, an adrenal
cortical steroid with a potent effect on sodium
and potassium metabolism.6 In addition to hy-
pertension, patients with primary aldosteronism
may have muscular weakness and periodic at-
tacks of actual paralysis associated with low lev-
els of serum potassium. Polydipsia and polyuria
may accompany this syndrome because of the
kidney’s inability to excrete concentrated urine.
Edema is rare in spite of sodium retention caused
by aldosterone.

The physical examination is not helpful, for
the tumors are too small to be palpated.

The characteristic laboratory finding that
should direct the clinician’s attention to the pos-
sibility of primary aldosteronism is a low con-
centration of potassium in the serum, usually
less than 3 mEq. per liter. The typical history
of muscular weakness and periodic paralysis
should be the clue for the physician to order a
test of the serum for potassium. Unfortunately,
some patients with primary aldosteronism have
hypertension without unusual symptoms to alert

474

THE JOURNAL-LANCET

the physician. The expert electrocardiographer
may see changes in the electrocardiogram which
suggest hypokalemia. These include depression
of the S-T segment, reduction of amplitude 01-
even inversion of the T wave, and increase in
the amplitude of the U wave. Prolongation of
the Q-T interval as an indication of hypopotas-
semia has been disputed.7

A persistently dilute and alkaline urine is also
a warning signal. However, in spite of all these
helpful clues, the limitations of our present
knowledge of this unusual condition are such
that cases of primary aldosteronism may be
overlooked unless tests for serum potassium are
routinely obtained for hypertensive patients.

Two pitfalls should be avoided in interpreting
serum potassium levels:

1. The low concentration of serum potassium
so characteristic of primary aldosteronism may
revert toward normal if the patient is on a diet
restricted in sodium, thus depriving the physi-
cian of his most valuable diagnostic aid. Con-
trariwise, diets high in sodium tend to accentuate
the hypokalemia.

2. Chlorothiazide (Diuril), which is now be-
ing used so widely as an antihypertensive agent,
lowers the serum potassium for most patients,
sometimes to levels low enough to cause confu-
sion in the diagnosis of primary aldosteronism.
The physician must be on guard against this
type of iatrogenic hypokalemia.

In addition to hypokalemia, there may be hy-
pernatremia and alkalosis. Urinary ammonia is
high, and the urine is neutral or alkaline.

Determination of aldosterone in the urine is
difficult and time-consuming and, unfortunately,
not very specific. Normal levels have been re-
ported with the characteristic syndrome and a
proved tumor.8 On the other hand, elevated lev-
els of aldosterone have been found in the urine
of patients with congestive heart failure, cirrho-
sis, and nephrosis and even in normal patients
whose intake of sodium was restricted.9’10 It is
essential, therefore, that patients be on unre-
stricted sodium diets when urine is collected for
this test.

Chronic renal disease may produce abnormali-
ties in serum electrolytes which are similar to
those produced by primary aldosteronism, and
primary aldosteronism, if untreated, may result
in chronic and irreversible renal damage. A most
difficult diagnostic problem, then, is to differen-
tiate between primary aldosteronism with sec-
ondary renal damage and primary renal disease
leading to secondary aldosteronism. Sodium re-
striction is helpful in this regard, since the uri-
nary sodium usually falls to nearly zero in pri-

mary aldosteronism, but, in chronic renal failure,
urinary loss of sodium continues despite sharp
reduction of sodium intake.11

At best, knowledge concerning primary aldo-
steronism is as incomplete as it is recent, and
surgical exploration will be necessary for diag-
nosis in equivocal cases until this problem is
understood better.

In most cases reported so far, aldosteronism is
due to adrenal cortical adenomas, and resection
corrects the abnormal serum electrolytes and
usually alleviates the hypertension, though not
always permanently. In rare cases, aldosteronism
has been associated with malignant adrenal cor-
tical tumors,10 and, in some cases, hyperplasia
without tumors has been encountered.11 Subtotal
resection of the adrenal glands is recommended
for hyperplasia.

UNILATERAL RENAL DISEASE

Finally, in the search for curable causes of hy-
pertension, the kidney should be considered.
For many years, it has been recognized that bi-
lateral renal disease, such as chronic glomerulo-
nephritis or chronic pyelonephritis, is frequently
associated with hypertension. But, only when
disease is confined to one kidney leaving the
opposite one unaffected is hypertension poten-
tially remediable by surgical means. Unilateral
renal disease as a cause for hypertension is a
concept that has been exploited clinically for
only the last twenty years. Unilateral renal dis-
ease, though rare, is the most common single
cause for potentially curable hypertension.

This condition can best be discussed by divid-
ing it into (1) parenchymal disease and (2)
occlusive disease of the renal artery.

Parenchymal disease. This includes chronic
atrophic pyelonephritis, hydronephrosis, tubercu-
losis, calcareous pyelonephritis, renal cysts, pyo-
nephrosis, and renal carcinoma.

In the majority of cases, the history and phys-
ical examination fail to give any leads directing
attention to unilateral renal disease as a cause
of hypertension. This is why intravenous pyelo-
grams are advocated for every patient who does
not have azotemia and whose hypertensive vas-
cular disease is severe enough and whose gen-
eral condition is sufficiently good to warrant sur-
gical treatment if a remediable lesion of one kid-
ney is discovered.

Our experience indicates that approximately
50 per cent of patients with chronic atrophic
pyelonephritis benefit from nephrectomy in that
the blood pressure is significantly reduced for
as long as fifteen years.1213 Approximately 30
per cent remain normotensive. Results from

NOVEMBER 1958

475

nephrectomy tor other types of unilateral renal
disease are not as satisfactory13 but are still
good enough to justify the risk of nephrectomy
in patients whose hypertensive disease is suffi-
ciently severe to present a problem in manage-
ment.

Unfortunately, there is no way to predict in
advance which patients will derive benefit from
nephrectomy. In general, the more severe the
renal disease, the more likely that nephrectomy
will reduce blood pressure, but there are many
exceptions. The longer the hypertension has ex-
isted, the less the chance that improvement will
follow nephrectomy; but, again, there are enough
exceptions to justify obtaining routine intrave-
nous pyelograms regardless of the duration of
the hypertension. Surprisingly, the age of the
patient seems to have little bearing on the result
obtained by nephrectomy. In general, patients
with hypertensive changes in the retina of groups
1 and 2 are more apt to be helped than patients
with changes of groups 3 and 4.

The only absolute contraindication to nephrec-
tomy is impaired function of the opposite kidney.
On the other hand, removal of a relatively nor-
mal kidney or a diseased kidney is scarcely justi-
fied if the hypertension is not severe enough to
pose a problem in management, unless, of course,
there are urologic indications for nephrectomy
over and above the hypertensive disease.

Occlusive disease of a renal artery. Recently,
Poutasse and Dustan'4 15 have shown that par-
tial or complete occlusion of the renal artery can
lead to reversible hypertension.

The typical patient with this syndrome reveals
a history of sudden onset of severe pain in the
Hank which lasts a day or two and is sometimes
accompanied by hematuria. Hypertension is first
discovered shortly thereafter or pre-existing hy-
pertension becomes more severe and difficult
to control. Most patients with this syndrome,
however, fail to give this characteristic history
suggesting renal disease, and the clue to diagno-
sis is derived from an intravenous pyelogram
ordered as a routine procedure for patients with
hypertension.

The affected kidney usually shows poor or de-
layed function and is smaller than its mate.
Sometimes the dye appears promptly and in
liood concentration in the affected kidney, and
a minimal disparity in size ( measured from pole
to pole) on the pyelogram between the two kid-
neys is the only indication of pathologic lesions
in the kidneys. Poutasse14 stated that any dif-
ference in length greater than 1 cm. must be re-
garded with suspicion.

Retrograde studies of renal function are also

helpful in detecting a partially ischemic kidney.
The volume of urine excreted per unit of time
by the affected kidney is less than that excreted
by the normal kidney. Moreover, the concentra-
tion of solutes may be less on the affected side.

Confirmation of the diagnosis depends on vis-
ualization or nonvisualization of the renal ar-
teries and their branches bv translumbar aortog-
raphy.

Strange as it may seem, the excretory urogram
may be absolutely normal in spite of occlusive
disease of adrenal artery or its branches. Such
conditions will not be discovered unless aortog-
raphy is routinely performed for all patients with
hypertension — a highly impractical if not im-
possible feat.

However, Poutasse and Dustan15 advocated
routine aortograms for ( 1 ) hypertensive patients
less than 35 years of age with no family history
of hypertension; (2) for hypertensive patients
over 55 years of age in whom the syndrome of
malignant hypertension develops; and (3) for
hypertensive patients at any age who suddenly
experience an exacerbation or rapid progression
of their disease, especially if preceded by an
episode of pain in the flank.

Treatment is surgical. If possible, direct ar-
terial surgery to replace or bypass the obstruct-
ed renal artery is the procedure of choice since
it preserves the kidney. If this is not technically
feasible, nephrectomy is carried out, provided,
of course, that the opposite kidney is normal.
Bilateral disease of the renal arteries has been
successfully treated with reconstructive arterial
surgery on both sides or on one side followed
bv nephrectomy on the other. The hypertension
usually remits or is significantly ameliorated if
an ischemic kidney is removed or its circulation
is restored.

SUMMARY

Every hypertensive patient whose disease is se-
vere enough to warrant treatment and whose
general condition is such that surgical procedures
are not contraindicated deserves a thorough
search for causes that are potentially curable.
The history can be extremely helpful in ferreting
out those patients with pheochromocytoma and
primary aldosteronism. It is moderately helpful
in detecting Cushing’s syndrome and occlusive
disease of a renal artery. It is of least value in
coarctation of the aorta and unilateral disease
of the renal parenchyma.

In most cases, Cushing’s syndrome and coarc-
tation of the aorta are brought to light during a
careful physical examination. Physical examina-
tion is of less value in the other conditions.

476

THE JOURNAL-LANCET

Since many cases of secondary hypertension
escape detection in spite of a carefully elicited
history and careful examination, certain labora-
tory aids should be resorted to more or less rou-
tinely for every hypertensive patient.

In the final analysis, even the most expert phy-
sician finds potentially curable lesions in less
than 5 per cent of hypertensive patients, and
many of these patients fail to derive the desired
benefit from surgical treatment.

Though the search is arduous and the yield
low, lives can be saved and disability prevented
bv the conscientious physician who persists in
seeking curable causes of hypertension.

REFERENCES

1. Kvale, W. F., Roth, G. M., Manger, W. M., and Priest-
ley, J. T.: Present-day diagnosis and treatment of pheo-

chromocytoma : review of 51 cases. J.A.M.A. 164:854, 1957.

2. Gifford, R. W., Jr., Roth, G. M., and Kvale, W. F.:
Evaluation of new adrenolytic drug (Regitine) as test for
pheochromocytoma. J.A.M.A. 149:1628, 1952.

3. Manger, W. M.: Pressor amines in pheochromocytoma.

Minnesota Med. 41:296, 1958.

4. von Euler, U. S., and Strom, G.: Present status of diag-
nosis and treatment of pheochromocytoma. Circulation 15:5,
1957.

5. Sprague, R. G., and others: Cushing’s syndrome: progressive
and often fatal disease. Arch. Int. Med. 98:388, 1956.

6. Conn, J. W., and Louis, L. H.: Primary aldosteronism, a

new clinical entity. Ann. Int. Med. 44:1, 1956.

7. Surawicz, B., and Lepesciikin, E.: Electrocardiographic

pattern of hypopotassemia with and without hypocalcemia.
Circulation 8:801, 1953.

8. Milne, M. D., Muehrcke, R. C., and Aird, Ian: Primary

aldosteronism. Quart. J. Med. 26:317, 1957.

9. Bartter, F. C.: Role of aldosterone in normal homeostasis

and in certain disease states. Metabolism 5:369, 1956.

10. Luetscher, J. A., Jr.: Aldosterone. Advances Int. Med. 8:
155, 1956.

11. Bartter, F. C., and Biglieri, E. G.: Primary aldosteronism:
clinical staff conference at the National Institutes of Health.
Ann. Int. Med. 48:647, 1958.

12. Barker, N. W.: Hypertension and unilateral renal disease.

M. Clin. North America 35:1041, 1951.

13. Thompson, G. J.: Results of nephrectomy in hypertensive

patients. J. Urol. 77:358, 1957.

14. Poutasse, E. F.: Occlusion of a renal artery as a cause of

hypertension. Circulation 13:37, 1956.

15. Poutasse, E. F., and Dustan, H. P.: Arteriosclerosis and

renal hypertension: indications for aortography in hyperten-

sive patients and results of surgical treatment of obstructive
lesions of renal artery. J.A.M.A. 165:1521, 1957.

Patients with parkinsonism should be examined for possible hyperthyroid-
ism, since treatment of the metabolic abnormality also alleviates symptoms of
parkinsonism.

In patients with hyperthyroidism and parkinsonism, symptoms of the latter
predominate. However, loss of weight and strength, heat intolerance, skin
flush, increased sweating, emotional lability, widened palpebral fissures, fixed
stare, tachycardia, and tremor are pathognomonic of both diseases. Tremor
in parkinsonism is coarse, irregular, and nonintentional and usually disappears
during sleep and increases during emotional excitement. In hyperthyroidism,
tremor is fine, rhythmic, and intensified bv extending the arms and spreading
the fingers. Increased appetite and velvety smooth, warm, moist skin are char-
acteristic of hyperthyroidism but not of parkinsonism. Thyrotoxic myopathy,
which occurs only in hyperthyroidism, improves rapidly after function of the
thyroid gland is restored to normal.

Radioactive-iodine uptake studies, serum protein-bound iodine determina-
tions, and basal metabolic tests help establish diagnosis of hyperthyroidism
accompanying parkinsonism. As a final procedure in questionable cases, the
basal metabolic test using thiopental sodium (Pentothal Sodium) anesthesia
is the most practical, inducing a perfect basal state void of all nervous and
muscular factors. After administration of Pentothal Sodium, metabolic rate
drops about 8 per cent in healthy persons but varies little in hyperthyroid
patients. The usual amount of Pentothal Sodium necessary to induce sleep is
0.5 gm. in healthy persons and as much as 2 gm. in patients with hyper-
thyroidism.

Elmer C. Bahtels, M.D., and Rene R. Rohart, M.D., Lahey Clinic, Boston. Arch. Int. Med.
101:562, 1958.

NOVEMBER 1958

477

Premature Resort to X-Ray Therapy

A Common Error in Treatment of
Carcinoma of the Thyroid Gland

J

E. A. CARR, JR., M.D., W. S. DINGLEDINE, M.D., and
W. H. BEIERWALTES, M.D.

Ann Arbor, Michigan >

Patients with papillary or Follicular carci-
noma of the thyroid gland may live a rela-
tively long time with or without aggressive
treatment.12 It is not our purpose here to dis-
cus whether or not treatment of such patients
should be attempted. However, we do believe
that if treatment is attempted, as much neo-
plastic tissue as possible should be removed
short of mutilation of the host. A logical se-
quence of therapy is excision of suspicious thy-
roid tumor and sampling of jugular nodes for
frozen section examination, total thyroidectomy
if the thyroid gland is found to contain carci-
noma, modified radical neck dissection if the
cervical chain of nodes contains carcinoma, I131
therapy if concentration of iodine by thyroid
tissue persists, and x-ray therapy if or when no
iodine concentration is demonstrated when car-
cinoma is known to persist.

The position of University Hospital at Ann
Arbor as a referral center gave us an oppor-
tunity to try to answer 2 questions: (1) In
practice, does x-ray therapy usually follow sur-
gical extirpation and I131 therapy? (2) Is the
patient any worse off by having x-ray therapy
before surgery and I131?

METHODS AND MATERIAL

Forty-two patients who had received x-ray ther-
apy for carcinoma of the thyroid gland were seen
in the Clinical Radioisotope Unit of University
Hospital between September 1947 and May 1957
and form the subject material for this report.
For statistical purposes, the study was considered
closed as of May 1957. Thus, in subgroup Ha,
which is described later, the last report used in
calculations of survival, follow-up, and so forth
represents the last report before the closing date

e. a. carr, jr., and w. h. beierwaltes are affiliated
with the Department of Medicine at University Hos-
pital, Ann Arbor, w. s. dingledine practices inter-
nal medicine in Richmond, Virginia.

of the study, even though in several cases, still
later reports showed that the patients were do-
ing well. In no instance do we know of a death
occurring after the closing date. Microscopic
pathologic confirmation of the diagnosis was a
prerequisite for inclusion of a patient in this
study. One author personally observed each
patient, and many of the subjects have also been
followed by one or both of the other authors.
Those patients who had been subjected to the
logical sequence of treatment previously out-
lined were classified as group I. Patients ex-
posed to x-ray therapy before surgical or I131
ablation of thyroid tissue were classified as
group II, subject to the following exceptions:
(a) failure to use I131 before 1948 was never
classified as an error, (b) no patients with histo-
logic diagnoses other than follicular and papil-
lary adenocarcinoma were included in group II.
and (c) the surgeon’s judgment was accepted
without question regarding limited extirpation.
The principal criterion of incomplete surgical
effort was failure even to attempt a total thyroid-
ectomy. Patients thus eliminated from group
II were added to group 1.

Patients in group II were further put in sub-
group I la if their course after x-ray therapy
had clearly shown that they had actually suf-
fered ill effects because x-ray therapy had been
prematurely administered before indicated sur-
gery and/or I131 therapy. Criteria for judging
whether the patient had suffered such ill effects
were: (1) localization technics at some time after
x-ray therapy’s completion showed metastatic
neoplasm concentrating I131 in every case except
11, the area of uptake being definitely metastatic
and not merely thyroid bed; (2) subsequent sur-
gery and/or I131 therapy gave objective benefit,
at the minimum a decrease in metastatic neo-
plasm concentrating I131; (3) the general condi-
tion was never worse after this local evidence
of successful treatment; (4) all patients were
alive and active within the last year.

478

THE JOURNAL-LANCET

RESULTS

Of the 42 patients in this series, 18 or 40 per
cent, fell in group I and 25, or 60 per cent, in
group II. Of the patients in group II, 13 or 31
per cent of the entire series, fell in subgroup 1 1 a.
Our last follow-up report was less than five
months before the close of the study in 11 pa-
tients and not more than ten months before close
of the study in any patients in subgroup I la.

The following results were obtained when I131
therapy, with or without further surgery, was
instituted after x-ray therapy in the 13 patients
in subgroup I la. Five had additional surgery
before I131 uptake in metastases was shown.
Metastatic neoplasm concentrating I131 disap-
peared in 12 and decreased in 1. Eight exhibited
further objective evidence that I131 therapy,
with or without surgery, was followed by re-
gression of metastases as judged by palpation
of the neck, x-ray films of the lungs, or both.
X-ray evidence of pulmonary metastases dis-
appeared in 2 and decreased in 2. Palpable
metastases disappeared in 4 and decreased in 3.
The regression of palpable metastases followed
I131 therapy alone in 6 of these 7 and followed
combined surgical and I131 attack in the re-
maining patient. One patient whose palpable
metastases disappeared only as an obvious and
direct result of surgery has not been included in
the aforementioned 8.

The mean survival time (if subgroup I la be-
tween the date the diagnosis was established
and date of the last report was six and one-half
years, with a range of two to ten years.

In 11 patients in subgroup Ila, records of the
total dose of x-ray received were obtained from
the roentgenologists giving the treatment. The
mean of these total doses was 5,055 r (standard
deviation ± 2,630 r) measured in air. Although
the majority of the patients were given daily
doses for several weeks until the course of
radiation was completed, a few received di-
vided courses of treatment at widely separated
intervals. It is, therefore, recognized that this
mean figure probably does not have precise
significance. We merely wish to show that the
patients received a reasonable amount of x-ray.
The decision to rely on x-ray therapy was made
while 11 of the patients in subgroup Ila were
under the direction of teaching or large city
hospitals. This decision was made after 1947
in 20 patients in group II, including 12 in sub-
group Ila, and after 1951 in 12 patients in group
II, including 5 in subgroup Ila.

Data on the individual patients in subgroup
Ila are summarized in table 1.

The following summaries of 3 illustrative cases

emphasize the importance of carrying out sur-
gery and I131 treatment before x-ray therapy.

Case 1. D. T., a 14-year-old girl, was found to have a
tumor in the region of the right jugular chain of nodes
in 1947 during a routine physical examination. No diag-
nostic or therapeutic measure was carried out. Eighteen
months later, a left axillary lymph node was palpated,
biopsied, and reported as showing no evidence of carci-
noma. In June 1949, lymph nodes removed from each
of the jugular chains were found to be the site of meta-
static adenocarcinoma of the thyroid gland. The parents
were allegedly told that surgery would involve resection
of the trachea, and x-ray therapy and I);u were ad-
vised and given. The patient received “20 treatments,
maximum dosage.” The lymph nodes had been re-
moved after a tracer of U*R and by absolute beta assay
were found to concentrate I131 well. Unfortunately, the
patient was given only 65 me. of H3i in 2 divided
doses in a medical school hospital elsewhere during
August and September of 1949. The patient was
asymptomatic and, on repeated check-ups, was con-
sidered well. During her senior year of nursing school
at our University Hospital, she consulted one of the
authors even though she was asymptomatic. Her scin-
tiscan (figure la) in June 1954 showed good uptake
in the region of both lobes of the thyroid gland and
apparently some uptake lateral to the thyroid gland,
presumably in cervical lymph nodes.

A radiogram of the chest showed that accentuated
vascular markings read on her chest roentgenograms
since 1950 were now beaded in appearance, suggesting
carcinoma of the thyroid gland metastatic to the lungs.
At surgery in August 1954, complete resection was im-
possible because of solid involvement of most of the
lateral structures of the neck. A wedge-shaped sagittal
block of hard fibrous tissue surrounding the trachea was
resected, thus freeing the trachea. The histologic diag-
nosis was moderately well-differentiated follicular and
papillary carcinoma of the thyroid. In February 1955,
after 3 months of propylthiouracil therapy, a scintiscan
showed uptake in the jugular lymph node areas (figure
lb) and probably in the left lower chest posteriorly.
Accordingly, the patient was given 145 me. of I131.
By May 1955, no I131 concentration could be dem-
onstrated in the neck (figure lc). The chest radio-
gram, however, was reported as still showing “bilateral
nodularity in both lower lungs, probably due to meta-
static neoplasm from carcinoma of the thyroid.” Ac-
cording to the scintiscan, there was questionable local-
ization of I131 in the region of the lung metastases, and
the patient was not yet myxedematous. Accordingly, she
was given 165 me. of I131. In August 1955, the meta-
stases had decreased in size and number, and the pa-
tient was totally myxedematous. She was put on de-
siccated thyroid medication, and the dosage was raised
to 3 gr. per day. She later gave birth to a normal
child. Her last chest radiogram, January 1957, was
read by the Department of Radiology as negative.
There was no visible or palpable thyroid tissue or carci-
noma in the neck. The scintiscan taken six weeks after
she had ceased taking thyroid, showed no localization of
I131 in neck (figure Id) or chest.

Case 2. M. I., born in 1931, received a total of
1,800 r of x-ray irradiation for tumors in the right jugu-
lar area in 1943 and 1945 with no regression of the
tumor. In 1947, a biopsy of the right cervical tumor
mass revealed “a somewhat undifferentiated adenocarci-
noma of the thyroid, infiltrating adjacent tissue.” A
recurrent tumor in this area was excised in 1948. In

NOVEMBER 1958

479

TABLE 1

Summary of 13 Patients with Follicular or Papillary Carcinoma of the Thyroid Gland Who
Had Neoplasm Concentrating I131 Remaining after X-ray Therapy and Who Benefited
from Further I'31 and Surgical Treatment

Case

Pt.

Race

Sex

Age at time
of diagnosis

Year of
diagnosis

Surgery ( other than biopsy)
and I131 studies or treatment
before x-ray Rx.

X-ray Rx
(Dose date )

Evidence of metastatic
neoplasm after x-ray Rx

i

DT

w

F

16

1949

None

“Maximum” 1949

Uptake in cervical nodes in
1949 and 1954; metastases
in cervical nodes palpable and
confirmed at operation in
1954; lung metastases in
1954-1955

2

MI

w

F

16

1947

None

1 ,800 r ( total )
1943 and
1945

Uptake in cervical nodes,
palpable cervical metastases,
lung metastases, and possible
rt. vocal cord involvement in
1950

3

EH

w

F

14

1952

Scan before surgery, total
thyroidectomy, rt. radical
neck dissection in 1952

6,000 r 1952

Uptake in cervical nodes,
palpable cervical metastases
in 1952

4

AH

w

M

11

1946

None

2,400 r 1946

Recurrent cancer in neck
found at operation in 1948;
uptake in cervical nodes in
1950; palpable cervical
metastases in 1950

5

GS

w

F

33

1948

Subtotal thyroidectomy in
1948

6,100 r 1948

Uptake in cervical nodes in
1954; lung metastases in 1954

6

HR

w

M

37

1952

Uptake study in 1952

5,500 r 1952

Uptake in cervical nodes in
1954; uptake in lung
metastases in 1954

7

D VanB

w

M

7

1950

Total thyroidectomy in 1950,
rt. radical neck dissection in
1951

“20 treatments”
1951

Uptake in cervical nodes in
1951; palpable cervical
metastases in 1951

8

VJ

w

M

62

1948

Subtotal thyroidectomy in
1948, excision of recurrent
cancer in 1950

6,575 r 1948
4,875 r 1950

Uptake in cervical nodes in
1952; palpable metastases in
1952; metastases found at
operation in 1953, 1954, 1955

9

DE

w

M

38

1952

Subtotal thyroidectomy in
1952, excision of remaining
thyroid and radical neck
dissection in 1952

4,150 r 1952

Uptake in cervical nodes in
1953

10

GP

w

M

53

1951

Uptake study before total
thyroidectomy and left
radical neck dissection in
1951

5,600 r 1952

Uptake in cervical nodes,
probable palpable cervical
metastases, cervical meta-
stases found at operation in
1954

11

ES

w

F

11

1946

Subtotal thyroidectomy

4,000 r 1946

Uptake probable in cervical
nodes, cervical metastases
palpable and confirmed at
operation in 1956

12

WF

w

M

17

1951

Subtotal thyroidectomy in
1951

5,900 r 1951

Uptake in cervical metastases
in 1956

13

KP

w

F

44

1954

Subtotal thyroidectomy in

2,700 r 1955

Uptake in cervical metastases

1954, excision of remaining in 1956

thyroid, radical neck
dissection in 1955

480

THE JOURNAL-LANCET

Further Rx after x-ray Rx
Surgery I™*

type and date Total dose

Results at last report
lIU uptake Pulmonary

in metastases metastases

Palpable

metastases Notes

Subtotal
thyroidectomy
in 1954

c. 375 me.. Disappeared Disappeared Disappeared

1949-1955

See further comments
in text

Total thyroidectomy 332 me.. Disappeared Disappeared Disappeared See further comments

in 1950 1950-1951 in text

None

410 me.. Disappeared

1952-1955

Decreased

Total thyroidectomy 142 me.. Probable

in 1948 1949-1950 disappearance

Disappeared Postoperative bilateral

laryngeal adductor
palsy and
hypoparathyroid

None

c. 310 me.. Disappeared temp- Decreased Several hard cervical

1954-1955 orarily. May return nodes appeared 1956

Total thyroidectomy 585 me.. Decreased Decreased Decreased

in 1953 1954-1955

None 130 me.. Disappeared

1951-1952

No Change

L. rad. neck dissec-

c. 90 me..

Disappeared at last

Surgical removal

Developed radiation

tion in 1954, ex. of
metastases in 1954,
1955

1953

I™ study 1953

ulcer of skin of neck

None 100 me.. Disappeared

1953

None except further 100 me.. Disappeared Disappeared

biopsy in 1954 1954

Excision of cervical 126 me.. Disappeared Decreased

metastases in 1956, 1956

biopsy (neg. ) in 1948

Modified radical neck 97 me.. Disappeared See further comments

dissection in 1956 1956 in text

None 114 me.. Disappeared

1956

Postoperative

hypoparathyroidism

NOVEMBER 1958

481

Fig. 2. (Case 2). Roentgenograms showing disappearanc of pulmonary metastases after I131 treatment (see table 1
and text. (a). October 5, 1948, miliary lesions shown in both lungs. Only prior treatment had been x-ray therapy to
neck in 1943 and 1945. (b). October 10, 1950, decrease in number and size of lung metastases. On July 11, 1950,
a total thyroidectomy had been performed, and 62 me. of I131 had been given on julv 15, 1950. (c). February 8,
1952; patient had received 90 me. of I131 on October 13, 1950, 80 me. on February 3, 1951, and 100 me. on June
14, 1951. Further decrease in metastases.

482

THE JOURNAL-LANCET

June 1950, re-excision of local nodes was carried out,
and chest roentgenograms were reviewed. They showed
that miliary lesions had been present in both lungs and
progressive since 1948 (figure 2a), presumably meta-
static carcinoma from the thyroid gland. In July 1950,
we found, in addition, a right vocal cord paralysis and
bilateral hard cervical adenopathy in each jugular chain.
A total thyroidectomy was performed, but all the lymph
nodes could not be resected. The pathologic diagnosis
was “papilliferous adenocarcinoma of the thyroid, ap-
parently metastatic to lymph nodes.” Localization
counting revealed definite uptake in cervical nodes and
suggestive localization of I131 in the region of pulmo-
nary metastases. Between July 1950 and June 1951,
the patient was given a total of 332 me. of I131 in 4
doses. In retrospect, chest roentgenograms demonstrated
that the lung metastases decreased in number and size
after each treatment dose (figures 2 b and 2c). The pa-
tient was totally myxedematous by September 1951 and
showed no further significant uptake in cervical lymph
nodes or lungs. She was, therefore, put on desiccated
thyroid. Palpable cervical lvmphadenopathv disappeared
by February 1952. The chest roentgenogram was read
as normal by the Department of Radiology by August
1955. The patient has remained entirely well and has
had normal chest roentgenograms and delivered 2 nor-
mal children as of December 1956.

Case 12. W. F., a 17-year-old boy, was found to have
a solitary thyroid nodule on routine physical examina-
tion in July 1951. A moderately well-differentiated adeno-
carcinoma with lymph node metastases was discovered
by subtotal thyroidectomy on August 31, 1951. No
effort was made to have I’ 31 localization studies per-
formed. Instead, a total of 5,900 r of x-ray irradiation
was applied to his neck starting on September 7, 1951
The patient was referred asymptomatic to the Clinical
Radioisotope Unit in September 1956 for a routine
check-up. Localization of I131 was present in the
thyroid gland region and in the jugular node area at
the level of the left angle ol the mandible. A left radical
neck dissection was performed, and 97 me. of I131 was
administered for residual concentration of I131. In March
1957, a scintiscan showed no evidence ot Il:" localiza-
tion in the neck.

COMMENT

As our study was restricted to patients seen in
the radioisotope unit of a hospital that is pri-
marily a referral center, our statistics are prob-
ably biased. We are apt to see patients with
thyroid cancer if they are not doing well under
treatment elsewhere or if the physician con-
cerned with their management feels that some
possible benefit may be gained from I131 therapy.
Nevertheless, it is somewhat disheartening to find
that, whereas many patients with tumors are
likely to benefit from a plan of treatment that
logically removes as much thyroid tissue as pos-
sible and attempts to obtain useful concentra-
tions of 1 131 in remaining neoplasm, these princi-
ples of treatment are honored more in the breach
than in the observance, even in recent years.

It is, of course, quite unlikely that we studied
all patients at the exact time they showed the
maximum benefit from x-ray therapy. In a few

instances, I131 uptake studies may have been
carried out before there was time for the patients
to show maximum benefit from x-ray therapy,
and, in several cases, such treatment may have
helped control metastases for a considerable
period of time before we saw the patients. Fur-
thermore, it cannot be claimed that destruction
of all neoplasm concentrating I131 is equivalent
to destroying all neoplasm. Logically, however,
it is a step in the right direction. Nevertheless,
about one-third of our patients to whom x-ray
therapy had been given before maximum use
had been made of surgical and I131 theraj)y sub-
sequently had metastases which responded to
some degree— and, at times, to a striking degree—
to completion of surgical and I131 therapy. There-
fore, we strongly suspect that surgical and I131
therapy should be completed in these patients
before x-ray therapy is begun.

We have attempted no comparison between
I131 and surgery, as we do not consider these in
any way competitive.

Absolutely no personal criticism of physicians
giving x-ray therapy is intended. The decisions
to discontinue surgical and I131 therapy are not
usually made by the radiologists.

SUMMARY

1. The logical sequence of therapy in attemp-
ting to extirpate papillary or follicular carcinoma
of the thyroid should be removal of as much
normal and neojdastic thyroid tissue as possible
without mutilating the host, I'31 therapy if con-
centration of I131 persists, and x-ray therapy if
residual carcinoma is then suspected.

2. In 25 of 42 patients who had received x-ray
therajov for thyroid cancer, it had been given be-
fore completion of surgical and I131 treatment.

3. In 13 of these 25 patients, metastatic neo-
plasm concentrating I131 was present after x-ray
therapy and absent or decreased after subsequent
I131 and surgical treatment. Eight patients had
further objective evidence of regression of me-
tastases after I131 and surgical treatment were
completed. Pulmonary metastases disappeared
in 2 and decreased in 2; palpable metastases dis-
appeared in 4 and decreased in 3.

4. These results suggest that the sequence of
treatment outlined in paragraph 1 has merit.

Expenses of this study were defrayed in part By grants
from the Michigan Memorial Phoenix Project, an
American Cancer Society institutional grant, and the
Helen Wolter Memorial Cancer Fund.

REFERENCES

1. Sloan, L. W.: Of the origin, characteristics and behavior of
thyroid cancer. J. Clin. Endocrinol. 14:1309, 1954.

2. Ward, R.: When is malignant goiter malignant? J. Clin.
Endocrinol. 9:1031, 1949.

NOVEMBER 1958

483

Observations on Prevention of Death
in the Neonatal Period

HARRY MEDOVY, M.D., F.R.C.P.(C.)

Winnipeg, Canada

As can be seen from table 1, statistics having
to do with the causes of death in the neo-
natal period are verv much the same in this coun-
try as in Great Britain provided autopsy rates are
high. Where autopsies on dead newborn infants
are infrequently performed, an accurate diagno-
sis is often impossible. Clinical and autopsy
diagnoses are likely to be at variance about 40
per cent of the time. An infant may die with a
clinical diagnosis of respiratory failure due to
atelectasis and at post mortem be found to have
pneumonia. We have seen an infant in whom
intracranial hemorrhage was diagnosed before
death show severe malformation of the aorta
with no pathology in the brain at autopsy.

If we are interested in preventing needless
deaths in the first week of life, we must first
know as accurately as possible the actual cause
of death. Then, by reviewing all the informa-
tion obtainable about the pregnancy in question
and any preceding pregnancies, the labor room
record, the appearance of the baby and the pla-
centa at birth, and the nursery record, we must
determine whether the death was preventable
or not.

If it is decided that the death could have
been prevented, all the relevant data should be
reviewed at a meeting of the medical staff to be
sure that adequate steps will be taken to mini-
mize the likelihood of such a death occurring
again. Particular care must be taken to see that
available knowledge is efficiently applied and
that the standards of medical and nursing care
are the best possible.

Since April 1954, a perinatal mortality study
group, consisting of a pediatrician as chairman
and representatives from the Departments of
Pathology, Obstetrics, and Pediatrics at the Uni-
versity of Manitoba, has conducted a study of

harry medovy is professor and head of the Depart-
ment of Pediatrics at the University of Manitoba,
Winnipeg, Canada.

Paper presented in part at a postgraduate course
in pediatrics for general practitioners at the Univer-
sity of Minnesota, March 1958.

the cause and prevention of perinatal deaths in
Winnipeg. All babies born in 2 large general
hospitals, averaging a total of approximately
7,000 births per year, were included in the study.

An effort was made to obtain all the informa-
tion possible in regard to every pregnancy. When
an infant died, every effort was made to obtain
permission for an autopsy. The autopsy rate has
varied from 92 to 95 per cent during the period
of study, 1954 to 1957. Autopsies were done by
personnel interested in and familiar with the pa-
thology of the newborn infant. All information
obtained about each infant who died was then
assembled, recorded on punch cards, and dis-
cussed by the study group. In conference with
the head of the Obstetrical Department of each
hospital, a temporary classification regarding pre-
ventability was agreed upon. The classification
used was similar to that introduced by Kendall
and Rose1 (table 2).

Thus, for example, when an infant died as the
result of multiple congenital malformations, he
was classified as obstetric, nonpreventable, and
unavoidable (code A-II-6). On the other hand,
if an infant died of erythroblastosis because the
physician failed to recognize such a possibility
in spite of regular prenatal attendance by the
mother and had delayed diagnosis and instituted
treatment too late to save the life, the case was
then classified as obstetric and preventable, with
the physician at fault because of error in judg-
ment (code A-I-3).

Each infant’s death was reviewed at a regular
combined obstetric-pediatric meeting attended
by the physicians concerned in the cases. Every
opportunity was given to the physician to add
or correct information in our records. The classi-
fication agreed upon by the study group was then
put to a vote, and the result was recorded. The
spirit of these meetings can best be understood
by realizing that these conferences are designed
to determine preventability, not culpability. In
many instances, a physician voluntarily suggest-
ed that a particular neonatal death was pre-
ventable and indicated the course he would fol-

484

THE JOURNAL-LANCET

TABLE 1

ANATOMIC CAUSES OF DEATH IN DIFFERENT STUDIES

Postmortem Findings 0

Chicago
Areal
per cent

New York
Areal
per cent

London t
Hospital
per cent

Winnipeg
Hospital
per cent

Abnormal pulmnoary ventilation and diffusion

47.5

40.0

26.6

27.7

Malformations

13.5

19.0

15.0

14.4

Anoxia

4.2

5.0

5.0

13.8

Infection

10.0

5.0

12.2

12.6

Hemolytic disease

-

10.5

3.2

6.6

Trauma

18.3

17.0

18.1

6.0

Miscellaneous

1.0

-

5.4

5.4

Inconclusive and unknown

-

4.0

_

7.8

Per cent of prematures

79.1

54.2

71.8

68.0

Total deaths

10,000

955

221

160

Per cent of autopsies in series as a whole

89.0

35.0

100.0

92.0

“All figures for anatomic causes of death quoted in these cases are from autopsies only.
fThe London study was a pure autopsy study.

A — Obstetric
B — Pediatric
C — • Combined

TABLE 2

PHILADELPHIA CLASSIFICATION

I — Preventable
II — Nonpreventable
III — Unclassifiable

1. Inadequate prenatal care

2. Family at fault

3. Physician, error in judgment

4. Physician, error in technic

5. Intercurrent disease

6. Unavoidable disaster

low if such a case were to come under his care
in the future. These meetings have proved edu-
cational and informative as well as serving the
original purpose of pinpointing preventable peri-
natal deaths.

Out of 148 deaths in one of the hospitals, 19
were considered preventable. It is of interest
that preventability was more often associated
with the death of a full-term rather than a pre-
mature infant.

PREMATURITY AS A FACTOR IN NEONATAL
MORTALITY'

Most newborn deaths occur in infants weighing
5 lb. or less at birth. Although about 7 per cent
of births in Winnipeg are premature, over 60
per cent of all neonatal deaths occur in this
group. Most of these deaths are due to respira-
tory failure associated with hyaline membrane
formation, pulmonary atelectasis, or organ im-
maturity. Little can be done to prevent death
in this group in the light of our present knowl-
edge. If prematurity could be prevented, fewer
newborn deaths would occur. Prematurity re-
lated to toxemia, placenta previa, twin pregnan-
cy, and malnutrition can be controlled to some
extent, and the number of infant survivors in this

group is increasing. Prematurity can hardly be
prevented in the 60 or 70 per cent of cases in
which the cause of premature onset of labor is
not even known.

Death of the full-term baby is much more often
preventable. This is borne out by our own ex-
perience and by the New York study as well.
This is the group that merits our closest atten-
tion.

PREVENTABLE CAUSES OF NEONATAL DEATH

In general, the area of preventability was found
to be one or more of the following:

1. Inadequate prenatal care due to neglect on
the part of the patient and her family or difficul-
ties in making regular visits to the physician as
the result of economic or geographic factors. We
must make sure that there is no obstacle in the
way of adequate prenatal care. If cases of tox-
emia, placenta previa, and erythroblastosis are
to be recognized early enough to ensure the best
possible care, regular prenatal care is imperative.
Not only must health departments make sure
that no one regardless of economic status or
geographic isolation is denied this care, but phy-
sicians must take steps to ensure that the pre-
natal examination is thorough and consists of

O

NOVEMBER 1958

485

TABLE 3

APGAR= RATING

Sign

0

1

2

Heart rate

Absent

Slow, below 100

Over 100

Respiratory effort

Absent

Slow, irregular

Good crying

Muscle tone

Limp

Some flexion of
extremities

Active motion

Response to catheter in nostril
(tested after oropharynx is clear)

No response

Grimace

Cough or sneeze

Color

Blue, pale

Body pink,
extremities blue

Completely pink

more than having a nonmedical person weigh
the patient and check the blood pressure and
urine.

2. Failure to recognize in the newborn signs
of treatable diseases, such as pneumonia, erythro-
blastosis, congenital obstruction, or cardiac fail-
ure.

An alert, efficient nursing and resident staff are
recognized essentials in any hospital which cares
for newborn infants. It is important to set up a
system which ensures careful observation of new-
borns from the moment of birth and prompt rec-
ognition of important deviations from normal,
such as jaundice in the first twenty-four hours,
pallor, repeated vomiting, and respiratory dis-
tress.

W e have found Apgar’s- system of scoring the
infant (table 3) to be a most valuable device
to ensure not only a reasonably careful assess-
ment of the infant at the time of delivery but
also, and perhaps even more important, to focus
nursing and medical attention on those infants
who are most in need of observation and in
whom abnormal conditions are most likely to
develop during their nursery stay.

The scoring is recorded sixty seconds after
birth and may be done by anyone present at the
delivery — obstetrician, anesthetist, houseman, or
graduate nurse. The infant is examined and rated
according to color, breathing, heart rate, response
to stimulus, and activity. A score of 0, 1, or 2
is asigned as shown on the table. It has been our
experience that infants rating 6 or higher rarely
experience difficulty. On the other hand, infants
rating 2, 3, or 4 contribute to nursery morbidity
and mortality.

The sixty-second score is of interest later to the
physician dealing with an infant who seems re-
tarded or has convulsive episodes. It may help
a good deal in deciding whether the problem
arose postnatally or antenatally if the infant’s
condition and responsiveness at birth are known

w ith reasonable reliability. Too often nursery
records are inadequate, and the labor room rec-
ord may hardly mention the infant.

By means of formal teaching and conferences,
the nursing and house staffs must be taught the
importance of careful observation and the ne-
cessity of drawing the physician’s attention to
changes in the infant’s condition which may in-
dicate serious trouble. In this way, treatable sur-
gical obstructions, previously unsuspected hemo-
lytic disease, and infection may be quickly rec-
ognized and lives saved as a result.

3. Infection in the newborn accounts for 10
to 12 per cent of neonatal deaths in spite of ad-
vances in antibiotic therapy. Infection is usually
acquired prenatally and often takes the form of
“intrauterine” pneumonia. If infant deaths due
to this cause are to be reduced, treatment must
be on a prophylactic basis and by “anticipa-
tion." Deaths due to intrauterine pneumonia
occur within a matter of hours after birth. Treat-
ment must therefore start from the moment of
birth or should be given to the mother before
the baby is born if conditions favor the develop-
ment of intrauterine infection of the fetus.

What are these conditions? In general, infec-
tion can reach the fetus in 1 of 3 possible ways:

1. bv blood stream spread — maternal bac-
teremia

2. bv vaginal route — ruptured membranes

3. by vaginal route — intact membranes.

Maternal sepsis and blood stream infection of

the fetus probably occur infrequently, but, nev-
ertheless, antibiotics should be given to any
woman at term who is febrile if there is any
suspicion of a bacterial cause for the infection.

When membranes are ruptured for eighteen
hours or more before labor commences, the pos-
sibility of ascending infection of fetal membranes
and amniotic fluid must be seriously entertained.
It is generally considered that infection does not
become a practical problem until such a patient

486

THE JOURNAL-LANCET

actually goes into labor, but from that point on,
the risk to the infant increases with the length of
the labor. Blanc* has pointed out that in about
30 per cent of cases of intrauterine pneumonia,
membranes are intact at the onset of labor but
become considerably thinned and probably less
resistant to infection from below as the result
of a prolonged and difficult labor.

For several months, we have followed a plan
of prophylaxis which is instituted at the moment
of birth in all cases which present one or more
of the following features at delivery: (1) ma-
ternal fever due to any cause, (2) membranes
ruptured more than eighteen hours, (3) foul or
murky amniotic fluid, (4) prolonged or difficult
labor, and (5) excessive obstetric manipulation
or instrumentation.

Under these circumstances, 20,000 units of
crystalline penicillin is given every four hours,
30 mg. per pound of streptomycin everv twelve
hours, and 60 mg. per pound of chloramphenicol
every six hours. Treatment may be discontinued
at any time by the attending physician or con-
tinued after forty-eight hours with his approval.
This method ensures prompt institution of treat-
ment without waiting for evidence of neonatal
illness. In the case of premature rupture of mem-
branes, the mother should be treated in this man-
ner at the onset of labor.

We would like to be able to say that the use
of this prophylactic regime has reduced mor-
tality from prenatally acquired infection. We are
forced to admit that up until now we have been
disappointed with the results achieved. We have
had instances of death on the third or fourth
day from intrauterine pneumonia related to pre-
mature rupture of membranes with proved am-
nionitis and placentitis in spite of the applica-
tion of the above routine from the moment of
birth. It seems evident that neither the choice
of antibiotic, the time it is given, nor the dosage
will solve the problem. The state of development
of neonatal immune mechanisms and humoral
as well as cellular mechanisms may play a very
important part in the ability of the baby to
cope with infection. Studies into the mechanisms
of phagocytosis in the newborn and the role of
passive antibody and the Properdin system are
not far enough advanced to permit application
of this newly acquired knowledge to the man-
agement of infection in the newborn infant.

Postnatallv, acquired infection responds more
favorably to treatment, provided the diagnosis
is made early enough. One must not wait for
the usual signs of illness caused by infection.
Fever is often absent. The development of list-
lessness, anorexia, or periodic apneic spells may

indicate sepsis in a newborn infant. A high index
of suspicion is of the greatest value. Better to
treat a few infants unnecessarily than to over-
look infection as the cause of illness in a new-
born infant.

We have had several preventable deaths in
newborns who were born uneventfully and then,
after a day or two of apparently normal progress,
be came listless and anorexic, and finally cyanotic
spells or convulsive episodes developed before
they died. At autopsy, sepsis alone was demon-
strated as the cause of death. The clinical diag-
nosis in one such case was heart failure and in
another intracranial hemorrhage.

4. Erythroblastosis accounted for 6.6 per cent
of our neonatal deaths. Deaths from erythroblas-
tosis are largely preventable, provided an effi-
cient system is in operation which permits ( 1 )
early identification of Rh mothers, (2) careful
checking of antibody levels throughout the preg-
nancy, and (3) attendance by an experienced
“transfusion officer” at the birth of a baby who
is apt to be affected.

Case finding in the Province of Manitoba is
supervised by the Blood Group Laboratory,
which is housed in the Maternity Building. Three
young, well-trained pediatricians are on call for
immediate care of any infant who is born with
hemolytic disease caused by blood group incom-
patibility. Exchanges have been started less than
twenty minutes after birth of a severely affected
baby. Occasionally, in carefully selected intances
and after careful review of the history of the
previous pregnancy, early induction is carried
out and is followed by prompt exchange trans-
fusion repeated 3 or 4 times if necessary in order
to try and salvage a healthy living baby.

4. Physician at fault is the category compris-
ing those cases in which an error in judgment
or technic on the part of the attending physician
contributed to the neonatal death. Such cases
include instances in which a cesarean section
was indicated in a particular case but for vari-
ous reasons was not performed, and a neonatal
death resulted. Also included in this category'
are instances of the incorrect use of forceps and
the misuse of drugs in the course of labor. It is
hardly necessary to state that a high standard
of professional competency must be expected of
any member of a hospital staff. Review of neo-
natal deaths by hospital staff phvsicians will help
to ensure that this desirable objective is main-
tained.

SUMMARY

1. Preventable neonatal deaths still occur.

2. Opportunitv for the prevention of neonatal
deaths is greatest in full-term infants.

NOVEMBER 1958

487

3. Further reduction in premature deaths
awaits results of research now in progress.

4. Inadequate prenatal care resulting from
maternal ignorance or economic or geographic
factors is responsible for neonatal deaths in many
instances.

5. A plan is outlined to ensure a high standard
of care of the newborn infant with emphasis
placed on prompt recognition and appreciation
of important signs of illness.

6. Accurate diagnosis of the causes of neonatal
deaths and a review by members of the medical
staff of each hospital of all the factors concerned

should lead to improved medical care in the peri-
natal period and to reduction in neonatal mor-
tality.

Statistical material in this paper is derived from the files
of the Perinatal Mortality Project conducted in Winnipeg
with the assistance of a Dominion-Provincial Health
Grant.

REFERENCES

1. Kendall, N., and Rose, E. K.: A mechanism of studying

neonatal mortality. Pediatrics 13:496, 1954.

2. Apgar, V.: Proposal for new method of evaluation of new-

born infant. Anesth. & Analg. 32:260, 1953.

3. Blanc, W. A.: Role of the amniotic infection syndrome in

perinatal pathology. Bull. Sloane Hospital for Women 3:79,
1957.

Neonatal osteomyelitis differs greatly from acute osteomyelitis in older
children. Early symptoms are nonspecific: malaise, failure to gain weight,
fever, diarrhea, refusal to move the affected part, local edema, wrist drop,
swelling of eyelids, conjunctivitis, purulent discharge from one nostril, thick-
ened gums, and abdominal mass. In contrast to osteomyelitis in older children,
toxemia and fever are not found, and the infant continues to eat well.

The bones that were affected most frequently in 24 patients were the
femur, maxilla, humerus, and vertebra. Roentgen examination is diagnostic
by the time of admission. The most prevalent sign is a large amount of ir-
regular extraeortieal new bone. Sequestra are prevented by good bone vascu-
larity in infants.

Osteomyelitis of the maxilla, found in one-quarter of the patients, is seldom
diagnosed before pus exudes from the sinuses. A swelling in the cheek, infra-
orbital area, or eyelid is usually the initial sign and may increase, redden, and
become abscessed or fistulous. Faulty deciduous teeth and nasal deformity
may result.

Staphylococcus aureus was isolated from all 24 patients and was uniformly
resistant to penicillin. Erythromycin should be started immediately, even before
diagnosis is confirmed, and continued in large doses for at least three weeks.
Pus should be aspirated frequently from joints, soft tissue spaces, and subperi-
osteal area and replaced with erythromycin in glycerin. Immobilization of
affected limbs is vital to prevent deformity, particularly in the hip joint. With
early diagnosis and adequate treatment, prognosis is good.

A. Murray Clarke, M.D., Melbourne, Australia. M. J. Australia 1:237, 1958.

488

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Uterus Didelphys — a Case Report

JOHN M. KELLER, M.D.

Williston, North Dakota

Congenital anomalies of a woman’s genital
tract are infrequently seen. Most of the re-
ports in the literature are of isolated cases, with
the exception of the large series of Fenton and
Singh1 and, most recently, that of Jones. Falls2
states that in a patient manifesting an absolute
sterility, or habitual abortion at the third to
fifth months, a bicornuate uterus must be strongly
suspected among other potential causes. The
gross fetal wastage approaches 40 per cent and
the cesarean section rate 20 per cent. In his
review of 107 cases of torsion of the gravid
uterus, Nesbitt* calls attention to the fact that
this accident was associated in 15 per cent of
these cases with a bicornuate uterus. Most cases
of bicornuate uterus deliver without incident,
and, therefore, are not recognized. Most authors
note an increase in postpartum hemorrhage,
premature labor, and abortion.1,2’4 Barter5 states
that the Strassmann unification operation is a
valuable procedure in women with anomalous
uteri who have had infertility problems or
habitual abortions.

A woman’s genital tract forms during the first
sixteen weeks of intrauterine life by fusion of
the 2 miillerian ducts. Canalization occurs, re-
sulting in 1 vagina, 1 cervix, and 1 uterus. Obvi-
ously, varying degrees of nonfusion may occur
with the resultant duplications of various por-
tions of the internal genitalia. Complete failure
of fusion yields the uterus didelphys, or the so-
called bicornuate uterus, with double cervix and
double vagina. The following is a report of such
a case.

CASE REPORT

Mrs. R. S., a 26-year-old white woman, Para 0-0-0-0,
had been married five years with an absolute infertility
problem. Catamenia was 14+28+4. Her past history re-
vealed that she had a previous infertility work-up, but
there was no evidence of tubal patency. A right ovarian
cystectomy was done in 1954. The patient was first
seen on January 13, 1956, at which time physical exami-
nation manifested a double vagina, double cervix, and
a double uterus, each side of which could be probed to
normal depth. The left vagina was patulous, and the
right was of approximately the same depth but not

john m. keller is on the staff of the Williston Clinic ,
Williston, North Dakota.

Fig. 1. Two uteri and left polycystic ovary as seen at
laparotomy.

easily examined manually. The left uterus was well
visualized by salpingography and showed a patulous,
normal appearing patent tube. The right uterus was
not cannulated but was probed to normal depth. Basal
metabolic rate was +8. Sims-Huhner test revealed active
sperm after two hours. Because of religious scruples, a
full sperm count was not available. The temperature
graph showed ovulation on the thirteenth day, which
was corroborated by vaginal smears. Because of the
patient’s long history of infertility and the physical and
laboratory findings, a unification operation was elected.
The husband and wife both agreed to this procedure.
On February 7, 1956, under cyclopropane, oxygen-
ether anesthesia, the patient was subjected to a two-
stage procedure. The first portion consisted of the re-
moval of the vaginal septum to the vault of the vagina
and a bilateral dilation and curettage. The second
portion consisted of an abdominal laparotomy with a
Strassmann unification operation and wedge resection
of the left polycystic ovary. Because the uterine in-
cision appeared to violate the integrity of the left tube
at its entrance into the uterus, this was cannulated with
polyethylene tubing, the distal end of which was passed
out into the vagina. Figure 1 shows the two uteri with
the left polycystic ovary as seen at laparotomy. Con-
valescence was uneventful, and the patient was dis-
charged on her sixth postoperative day. The polyethylene
catheter was removed six weeks postoperatively. A
second salpingogram (figure 2) was made showing the
single uterine cavity and bilateral patent tubes. The
patient became pregnant seven months after operation
and followed an uneventful prenatal course until the
thirtv-seventh week of gestation, at which time pain-
less uterine bleeding began. The diagnosis of placenta
previa was made, and an infant was successfully de-
livered by classical cesarean section. At operation,
there was no evidence of a scar in the uterus, except

NOVEMBER 1958

489

Fig. 2. Single uterine cavity and bilateral patent tubes.

for an area of dimpling between the uterosacral liga-
ments. Because of the double cervix and the nonforma-
tion of any discernible isthmus uteri, the classical cesar-
ean operation was elected. The patient was discharged
on her fifth postoperative day following a normal con-

valescence. She has not become pregnant since, by
choice.

SUMMARY

Anomalies of a woman’s genital tract may occur.
Many women have uneventful courses through-
out pregnancy and delivery. There is a high
incidence of abortion, premature labor, and
postpartum hemorrhage in cases of bicornuate
uterus. Awareness of this condition is the first
step toward satisfactory diagnosis.

REFERENCES

1. Fenton, R. H., and Singh, B. C.: Pregnancy associated with
congenital abnormalities of the female reproductive tract. Am.
J. Obst. & Gynec. 63:744, 1952.

2. Falls, F. H.: Pregnancy in the bicornuate uterus. Am. J.

Obst. & Gynec. 72:1243,' 1956.

3. Nesbitt, R. E. L., Jr., and Corner, G. W., Jr.: Torsion of
the human pregnant uterus. Obst. & Gvnec. Survey 11:311,
1956.

4. Eastman, N. J.: Pregnancy and labor in the bicornuate

uterus. Unpublished personal communication.

5. Barter, R. H.: Gvnecologic operations for infertility. Am.
Surgeon 21:818, 1955.

Culture of menstrual and intermenstrual secretions and endometrial
biopsy should be used together after hvsterosalpingography for the diagnosis
of genital tuberculosis. Although the lesions are usually self-limited and fre-
quently self-healing, pregnancies are successful only when the tuberculous
process is arrested in the tubal stage.

The onlv means available at present for the detection of tubal tuberculosis
is culture of the menstrual discharge. The disadvantage of this method is the
delay in obtaining definite results. Since tuberculous lesions of the endome-
trium and salpinx contain few bacilli, generally only 1 of 3 or 4 cultures is
positive.

The advantage of endometrial biopsy is speed. However, this procedure is
less accurate than culture and is positive only when the endometrium is affect-
ed. In 103 patients with latent tuberculosis, culture of menstrual and inter-
menstrual cervical and vaginal discharges produced positive results in 89 per
cent and biopsy in 63 per cent. In about 8 per cent of the cases in which
cultures failed to show tuberculosis, biopsy of the endometrium was successful.

Genital tuberculosis usually improves with streptomycin therapy but may
recur.

I. Hai.bhecht, M.D., Hasharon Hospital, Petah Tiqva, Israel. Am. J. Obst. & Gynec. 7.5:899. 1958.

490

THE JOURNAL-LANCET

Suppression of Lactation with an
Oral Androgen-Estrogen Preparation

MORRIS UNHER, M.D., and HARRY E. PETZING, M.D.
Buffalo, New York

The search for a satisfactory regimen for the
suppression of lactation has preoccupied ob-
stetricians for decades. The multiplicity of mo-
dalities currently in use testifies to the reality
and scope of the problem.

Aside from the age-long use of binders, local
ice packs, analgesics, cathartics, and fluid restric-
tion, the hormonal approach to the suppression
of lactation is the most widely favored today.
Its rationale derives from the various theories of
the hormonal effects responsible for the onset
and continuance of lactation.

RATIONALE OF HORMONAL TREATMENT

It is known that the lactogenic hormone of the
anterior pituitary gland, prolactin, is most di-
rectly involved in lactation.1 The breast is be-
lieved to be made more susceptible to the influ-
ence of this hormone by the action of proges-
terone and estrogen, which are both produced
by the placenta during pregnancy.2,3 Estrogen
levels are high during pregnancy and fall sharp-
ly after the delivery of the placenta.2 It is be-
lieved that progesterone exerts a prolactin inhibi-
tory effect and that the growth stimulus of estro-
gen on the breast reduces susceptibility to the
influence of prolactin.4 The fact is that the pro-
lactin content of the anterior pituitary gland is
high during pregnancy.5 However, evidence of
prolactin in the circulation, namely, the forma-
tion of colostrum and milk, does not appear until
after delivery. Selye and his group6 suggest that
suckling of the breast bv the newborn baby ac-
tivates a neuroendocrine reflex mechanism which
helps maintain an augmented secretion of pro-
lactin.

Therefore, on the basis of these facts and theo-
ries, hormonal treatment can suppress lactation
probably by either one of two separate endo-
crine effects: (1) secretion of prolactin may be

morris unher and harry e. petzing are associates
in the Department of Obstetrics and Gynecology at
the University of Buffalo Medical School and co-
chairmen of the Department of Obstetrics and Gyne-
cology at the Buffalo Columbus Hospital.

inhibited by suppression of anterior pituitary
function or (2) susceptibility of the breast to
prolactin can be eliminated.

EXPERIENCES WITH HORMONAL TREATMENT

Testosterone has been shown to suppress the
pituitary gland and to effectively inhibit lacta-
tion in mice.7 The first report of successful sup-
pression of lactation with this hormone in ob-
stetric patients was published by Kurzrok and
O’Connell.8 They found 50 to 150 mg. of testos-
terone propionate effective in 19 of 21 patients.

Doses of 25 mg. twice daily or 50 mg. once
daily were found more effective than a single
large dose of 150 mg. Administration in doses
up to 300 mg. per month was considered the
maximum amount compatible with safety and
freedom from undesirable side effects.

Estrogen in various forms has also been used
extensively to suppress lactation. Theoretically,
it too inhibits the pituitary, and its growth stim-
ulating effect inhibits the susceptibility of the
breast to prolactin. However, estrogen must be
administered for a long time — as long as thirty
days for complete suppression of lactation. It
is often ineffective if administered after lactation
has become established. Nausea, vomiting, with-
drawal bleeding, return of lactation, and en-
gorgement often occur with estrogen therapy.
These disadvantages were reported by Stewart
and Pratt,9 Walsh and Stromme,10 and Morton
and Miller.11 We have also observed these side
effects too often, for we used estrogen to sup-
press lactation for many years on our obstetrical
service.

EXPERIENCES WITH COMBINED TREATMENT

Dissatisfaction with estrogens led us to introduce
another method of treatment for the suppression
of lactation. An oral preparation containing 5
mg. methyl testosterone and 0.25 mg. dienestrol
per tablet, known as Estan, was introduced in
our obstetric department in August 1955. This
hormonal combination is said to have a syner-
gistic action, making possible effective therapy

NOVEMBER 1958

491

TABLE 1

SUMMARY OF RESULTS

T reatment

Number of
patients

Withdrawal

bleeding

Breast engorge-
ment and pain

Satisfactory

results

Estan t.i.d.

537

15 patients
(2.8%)

34 patients
(6,3%)

488 patients
(90.9%)

200 nig. androgen plus Estan t.i.d.

75

2 patients

4 patients

69 patients

( 1.6%)

(5.3%)

(93.1%)

with smaller, safer doses of each hormone.12
Published reports are very favorable toward this
preparation. Its routine use not only provides
the desired result but also prevents engorgement
and pain and does not cause withdrawal bleed-
ing.

Rienzo13 reported good to excellent results in
the postpartum suppression of lactation in 81.6
per cent of patients treated with this prepara-
tion. Edwards and Metoyer14 reported similar
results in 83.3 per cent of patients. Garry15 also
obtained good to excellent results in 83 of 100
postpartum patients treated with Estan. Laufe
and McCarthy16 found results were exceptionally
good in 95.5 per cent of patients who received
Estan according to the following special dosage
schedule that they devised. Treatment in all in-
stances was started as soon as possible within
the twenty-four-hour period after delivery. Each
patient received 3 Estan tablets three times a
day on the first and second postpartum days,
2 tablets three times a day on the third and
fourth postpartum days, and 1 tablet three times
a day on the fifth or last day.

METHOD AND RESULTS

Treatment for the suppression of lactation with
Estan was started as soon as possible after de-
livery on our obstetric service. Two tablets of
this androgen-estrogen preparation were admin-
istered three times a day for a minimum of five
days but more often for six or seven days, that
is, up to the time of the patient’s discharge.
These tablets are small, easy to administer, and
well tolerated by patients. During two vears of
routine use in our hospital, Estan produced more
satisfactory results than any other medication.

During the two-year interval between August
1955 and September 1957, a total of 721 patients
were delivered on our obstetric service, and 612
of these were treated with Estan for the sup-
pression of lactation. This androgen-estrogen
preparation effectively suppressed lactation with
virtual freedom from untoward side effects in
90.9 per cent of 537 patients who received no
other supplemental^ hormonal medication.

At first, because of our inexperience with this
form of treatment, 75 patients received an intra-
muscular injection of 200 mg. of long-acting an-
drogen in addition to the tablets. However, ob-
servations in patients treated with the androgen-
estrogen preparation alone soon showed that no
significant advantage resulted from the andro-
gen injections and, therefore, they were dis-
continued.

Fluid restriction was suggested but not rigidly
enforced. Adjunctive measures consisted of the
application of ice bags to the breast and the ad-
ministration of mild analgesics in the few in-
stances (6.3 per cent) in which pain and en-
gorgement occurred. Generally, these complica-
tions were minimized with this medication.
However, when they did occur, they were usu-
ally transitory and subsided within eighteen to
twenty-four hours. In no patient did the dura-
tion and intensity of breast discomfort compare
with that observed in patients treated with an-
drogen alone.

In contrast to our previous experience with
estrogen therapy, virtually complete absence of
withdrawal bleeding was a most striking and
gratifying advantage of combined hormonal
therapy. The incidence of recurrent lactation
after discharge was also “nil,” although it had
been a very frequent nuisance in the past when
we used estrogen. Disturbances in postpartum
menstruation did not appear in any of the pa-
tients treated with the androgen-estrogen prepa-
ration. Results of this therapy are summarized
in table 1.

CONCLUSION

Routine lactation suppression with an androgen-
estrogen tablet preparation has proved most sat-
isfactory and superior to other methods of treat-
ment that we have used for this purpose in the
past.

Treatment with the androgen-estrogen is ad-
vocated because:

1. Suppression of lactation was successfully
achieved with only very minimal breast engorge-
ment and pain.

492

THE JOURNAL-LANCET

2. Withdrawal bleeding and disturbed post-
partum menstruation did not occur.

3. The medication is small, easy to take, and
well tolerated by patients.

Estan was supplied for use in this study by White
Laboratories, Inc.

REFERENCES

1. Best, C. H., and Taylor, N. B.: The Physiological Basis of
Medical Practice, ed. 6. Baltimore: Williams & Wilkins Co.,
1955.

2. Williams, R. H.i Textbook of Endocrinology. Philadelphia:
W. B. Saunders Co., 1950.

3. Stricker, P., and Gruter, F.: Uber die Wirhung Eines Hy-
pophyen Vorderlappenhormones aus die Auslosung der Milch-
sekretion. Klin. Wchnschr. 8:2322, 1929.

4. Riley, G.: Essentials of Gynecologic Endocrinology. Ann

Arbor: Caduceus Press, 1948.

5. Meites, J., and Turner, C. W.: Studies concerning mechan-
ism controlling initiation of lactation at parturition; why lac-
tation is not initiated during pregnancy. Endocrinology 30:
719, 1942.

6. Selye, H., Collep, J. B., and Thompson, D. L.: Nervous

and hormonal factors in lactation. Endocrinology 18:237,
1934.

7. Robson, J. M.: Action of testosterone on lactation. Proc.

Soc. Exper. Biol. & Med. 36:153, 1937.

8. Kuhzrok, R., and O’Connell, C. P.: Inhibition of lactation
during puerperium by testosterone propionate. Endocrinology
23:476, 1938.

9. Stewart, H. L., Jr., and Pratt, J. P.: Inhibition of lacta-
tion. Am. J. Obst. & Gynec. 41:555, 1941.

10. Walsh, J. W., and Stromme, W. B.: Study of use of di-

ethylstilbestrol in inhibition and suppression of lactation. Am.
J. Obst. & Gynec. 47:655, 1944.

11. Morton, D. G., and Miller, J. S.: Suppression of lactation
with stilbestrol. Am. J. Obst. & Gynec. 62:1124, 1951.

12. Greenblatt, R. B., and others: Evaluation of estrogen, an-

drogen, estrogen-androgen combination, and placebo in treat-
ment of menopause. J. Clin. Endocrinol. 10:1547, 1950.

13. Rienzo, J. S.: Use of hormones for prevention of breast en-
gorgement and lactation. Am. J. Obst. & Gynec. 66:1248,
1953.

14. Edwards, L. F., and Metoyer, M. S.: Review of methods of
suppression of lactation in the puerperium and report of 108
cases treated with androgen-estrogen combination. J. Nat.
M. A. 47:239, 1955.

15. Garry, J.: Estrogen-androgen preparation for prevention of

postpartum breast engorgement and lactation. Obst. & Gynec.
7:422, 1956.

16. Laufe, L. E., and McCarthy, J. J., Jr.: An effective hor-
mone combination for the suppression of lactation. Pennsyl-
vania M. J. 59:914, 1956.

Difficult deliveries caused by an oversized fetus usually become evident
after the usual amount of fundal pressure or traction on the forceps fails.

Among 40,944 deliveries, 200 infants weighed over 10 lb. at birth. Of
these, 60 per cent were males, and 40 per cent were females. White women
are more apt to have oversized babies than Negroes. Increased maternal age,
multiparity, and previous large infants are all of some significance. Diabetes
mellitus and toxemia occur more frequently in mothers of large babies.

Presentation and length of labor are the same as with other infants. For-
ceps are used infrequently, which emphasizes the fact that delivery of the head
is not difficult. Impacted shoulders are the most serious complication. The
tight-ring maneuver described bv Barnum is useful. After deep general anes-
thesia, the posterior arm is delivered first by flexing the fetal elbow and then
sweeping the arm down over the anterior chest. At this point, the posterior
shoulder is out, but the anterior shoulder is still impacted against the symphy-
sis pubis. The infant is then rotated 180°, bringing the fetal back over the
midline of the mother’s abdomen to the side toward which the fetus originally
faced. The shoulder which was out then comes into position just outside the
symphysis, unlocking the obstruction.

The antenatal infant death rate is 7.7 times greater than normal. Placental
insufficiency may be a factor. The intranatal infant death rate, which is 15.6
times higher than the usual rate, can be accounted for by difficult deliveries.

Harvey A. Gollin, M.D., Averon H. Ellis, M.D., and Evan F. Evans, M.D., University of
Illinois, Chicago. Am. J. Obst. & Gynec. 75:742, 1958.

NOVEMBER 1958

493

Edward L. Tuohy, M.D.

By FRANK J. HIRSGHBOEGK, M.D.
Duluth, Minnesota

It is a privilege to be able to write of the life and
career of an outstanding personality in our pro-
fession. As an admirer of his many talents, I have
been chosen to review the accomplishments of this
man. His voice today repeats his lifelong aspirations
with the same ardor manifested in his service of fifty
years as a student, organizer, and teacher and, above
all, in his devotion to his profession and in the ideal-
ism for the advancement in the art and science of
the practice of medicine.

In response to my letter requesting more intimate
data of his life, Dr. Tuohy could not forego the
opportunity to give first place to the creed of his
professional pursuits: “Some of the more personal
facts can well be less emphasized, but you will see
that behind any progress that we may have made
with our lives lies the deep desire to give Duluth
and the area about it a medical atmosphere that is
such that the other great dominant sections of Min-
nesota may not, on the whole, pass up Duluth as
a lesser way-station. I cannot feel that this is a totally
immodest aim when one considers what the Twin
Cities, the University of Minnesota, and the great
Mayo institution have grown into.”

There could not be a more worthy ambition, and,
despite years of work and effort in the face of the
continuous struggle for better medical milieu in a
well-qualified area, all his professional associates,
intra- and extramural, express uniform approval of
his unselfish devotion to the cause of medicine. No
medical man is so highly regarded in the large area
of his leadership, and the goals that have been
reached attest to his influence.

A sense of humor, spoken of by Samuel Johnson
as “closely akin to a sense of proportion,” did not
lead to self conceit— that would detract from his
influence. His accomplishments have been centered

in the organization of greater teaching facilities
and advancement in hospital operation and medical
procedures rather than in personal medical practice.
Therein lies much of his selflessness in striving for
the greater good. His primary interest has been in
the younger doctor and his progress. Unlike Mizner,
who said, “Be good to the boys on the way up,
because you will meet them on the way down,” Dr.
Tuohv strove to elevate them all to a level of parity.

THE EARLY YEARS

Dr. Tuohv’s ancestors came from the counties of
Mayo and Galway in northwestern Ireland, a part
of the country truly Irish in its history and culture.
The land was never deeply invaded by the seafaring
Vikings, who preferred settling on the more acces-
sible coasts of the eastern part of the country; by the
Normans, in their conquest of the vallevs of the
southern streams; or by the few Spanish mariners,
who were stranded on the coast of the Irish Sea and
in the southern part of the country. The family
names are distinctly Gaelic, and these more remote
and secluded areas have adhered to their native
tradition of freedom. They are a rather pure race
and carry in their blood an intense patriotism and
the attributes of independence, loyalty, humor, and
a breadth of originality in their attitude toward all
phases of life.

Dr. Tuohv’s parents migrated to America in the
later middle years of the last century, and, in 1861,
the immediate forebears, Edward Tuohy and Mar-
garet Towey— a strange similarity in names— were
married in Winona, Minnesota, and became the par-
ents of 8 children, of whom Dr. Tuohy and an
older sister still survive. The family home was es-
tablished on a farm in Ghatfield, Minnesota, and it
was there that Dr. Tuohv was born in 1878. The

494

THE JOURNAL-LANCET

early years in Chatfiekl scliools were often inter-
rupted by absences, necessitated bv seasonal work on
the farm, but bis long struggle for an elementary and
high school education ended in June 1898, after at-
tending the latter for two years. The inherent talents
of the young student were recognized by bis high
school teacher, who said, “Eddie, you must go to
college, and I will help you finish high school in
two years if you will study without interruption bv
working on the farm.” With that inspiration, young
Edward learned how to study and, he adds, “After
that, the academic course at the University of Min-
nestoa was no more than child’s play.” Three years
later, in 1901, he entered the Medical School of the
University of Minnesota. His zeal for improvement
and study has never faltered and has proved a stimu-
lus to others. His recital of the names of Charles
Sigerfuss in biology and “Tommy” Lee in histology
betokens his admiration of them as instructors. In
his second year, he was appointed preceptor in his-
tology. However, he told Dr. Lee that he was in-
terested in clinical medicine and preferred to de-
vote a closer allied interest to pathology, which was
the root of medicine to him. This decision endeared
him to Dr. Frank Wesbrook, to whom Dr. Tuohv
refers as the “molding agent” in his life. Of no one
does be speak of as feelingly as an inspiration to bis
career. Dr. Wesbrook later became the first presi-
dent of the University of British Columbia, a position
that Dr. Tuohv spoke of as the climax in the life of
a great educator. In his later years as a medical
student, Dr. Tuohy’s interest in medicine was fos-
tered by an association with Dr. George Head and
Dr. Walter Sheldon as teachers.

On his graduation in 1905, he served for a short
period as an intern in St. Joseph’s Hospital, St. Paul.
At that time, internships were not well organized,
and, after a lapse of a few months, he was offered
a position at St. Mary’s Hospital in Duluth as intern,
head of the clinical laboratory, and pathologist, a
position which he accepted at the munificent salary
of $33 a month plus “keep and found!”

In his new position, he conducted all the intra-
mural activities and soon served also as a “gadfly”
to professional indifference (early evidence of his
activities in the years to follow). In his work in the
pathologic and clinical laboratory, he checked clini-
cal diagnoses, and he treasures the memory of cer-
tain early achievements, such as finding a hyper-
nephroma in a nephrotomy performed for what was
thought to be tuberculosis. Dr. Tuohy’s more ac-
curate histologic diagnoses were accepted by the
leading surgeons at the hospital sometimes with ap-
proval and appreciation and, at other times, with
disapproval and disgust. Nevertheless, the results
were greater accuracy in diagnostic methods and
improvement in hospital technic. Dr. Tuohy’s close
friendship with Dr. Braden, a surgeon at the hospit-
al, later led to his acquaintance and, finally, his as-
sociation with Dr. W. A. Coventry, an affiliation
which persisted until Dr. Coventry’s death a few
years ago. As director of the laboratory, a close

friendship arose with Bishop James McGolrick, who
was diocesan director of the hospital and who en-
couraged the Sisters of the Benedictine Order to
comply with Dr. Tuohy’s request for the forma-
tion of a good laboratory. This move led step by
step to innovations which added notably to the
efficiency of the institution and redounded to the
credit of the administrators of the hospital.

In 1907, Dr. H. M. Bracken, chief of the Minne-
sota Deparment of Health, urged Dr. Tuohv to move
to Duluth to serve as director of a branch office of
the State Board of Health. This position offered
him an opportunity to begin the private practice of
internal medicine, which he combined with excur-
sions into general practice and even an occasional
obstetric case. At this time, the first cystoscopic
examinations were being made, and a patient on
whom the first attempt at cystoscopy was made bv
Dr. Tuohv spoke to me in later years of his discom-
fiture at the procedure and some doubt as to its
value as a diagnostic measure!

In the same year of 1907, he married Ida M.
Boyce, who had been a student with him in the
academic school at the University of Minnesota.
Their only son, Edward, who followed bis father in
the choice of medicine as a profession, was born,
fittingly, on Saint Patrick’s Day, March 17, 1908,
and is presently an outstanding anesthesiologist in
Los Angeles. A few years later, in November 1911,
his only daughter Catherine was born.

It was in this period that Dr. Tuohv first evinced
an interest in the more adequate control and treat-
ment of tuberculosis. At that time, tuberculosis and
pneumonia were the most common causes of death,
and the vastness of the tuberculosis problem was
felt throughout the world. In 1908, he attended the
International Congress on Tuberculosis in Wash-
ington, D.C., where the leading phthisiologists of
the world were gathered. Bobert Koch was in at-
tendance and had not vet altered his opinion that
tuberculosis could be successfully treated with
tuberculin. However, Newsholme of Great Britain
inspired a deep interest in Dr. Tuohy with his views
concerning the possibilities of controling the dis-
ease bv segregation, thereby limiting its spread by
avoiding close contact with infected persons. Upon
bis return to Duluth, Dr. Tuohy enlisted the aid of
the citizens in the community to accept the sana-
torium method as the principle way to control the
disease. Legislation was drafted for the founding
of the first county institution in Minnesota for the
care of the tuberculous patient, which would aid in
the work already begun in the state tuberculosis
sanatorium at Walker, Minnesota. Organization for
building the hospital and its management were
fostered bv Dr. Tuohv, and his interest persisted as
a member and president of the sanatorium board of
St. Louis Countv for twenty-eight years. He was
fortunate in obtaining men of unusual capacity and
ability for superintendents of the hospital. Doctor
“Billy” Hart, a native Canadian, was the first super-
intendent, and, when he left Nopeming to accept

NOVEMBER 1958

495

another post, the commission of the sanatorium had
the good fortune in obtaining Dr. Arthur Laird as
his successor. During this period, great strides were
made in the control of the disease and in the pre-
vention of new infections. Under the superinten-
dency of Dr. G. A. Hedberg, who succeeded Dr.
Laird upon his retirement, the surgical treatment
of the disease came into recognized prominence and
was undertaken at the sanatorium. After Dr. Hed-
berg’s death a few years ago, Dr. R. W. Backus was
installed as superintendent, and, during the adminis-
trations of these men, the medical treatment of
tuberculosis came to fruition. In 1909, the death rate
in St. Louis County was 130 per 100,000 of popula-
tion, whereas, presently, it has been reduced to the
rate of 4 per 100,000— an achievement almost un-
equaled in the history of medicine and a lasting
tribute to the foresight of the early pioneers. This
period also marks the passing of an era in practice
in which clinical medicine was a dominating fea-
ture. The changes were the result of the tremendous
advances in health control, the use of the diagnostic
x-ray, improved laboratory studies, advances in chest
surgery, and, in the past few years, the addition of
medicinal aids that have revolutionized the treat-
ment of the “white plague” of fifty years ago.

Due to increased duties and other plans for his
future, Dr. Tuohy prevailed upon Dr. Thomas R.
Martin, a staunch and dear friend with unusually
admirable and zealous capacities, to come to Duluth
and take charge of the Duluth branch of the State
Board of Health. This marked a “turning point” in
Dr. Tuohv’s career, liberating him for future progress
and, at the same time, establishing a worthy succes-
sor to his post as well as effecting a close personal
and professional association that redounded to the
benefit of both these pioneers in health problems.
An effort was made to establish better medical care
for the poor in the area immediately contiguous to
Duluth. A method was devised whereby the vounger
physicians of Duluth could serve under the county
physician. Dr. Robert Graham, insuring better care
for the poor and an opportunity for them to supply
necessary medical care without cost to the county
and, at the same time, offering opportunities for
study and advancement in their practice. Meeting
opposition from many of his fellow practitioners,
Dr. Tuohy decided to go to Europe in 1912 to
study internal medicine, leaving the work of the
State Board of Health in the able hands of Dr. Mar-
tin.

THE YEAR IN VIENNA

After the early years of work in the hospital and
State Board of Health laboratories, the struggle to
control rampant tuberculosis, and the organization of
adequate facilities for the control and treatment of
tuberculosis at Nopeming in addition to the labor
of beginning private practice, the year of 1912 in
Vienna was a great adventure. Vienna at that period
was the hub of systematized medical study in all its
branches. Under the aegis of the American Medical

Association, courses were well organized, and a
center for registration and graduate curricula was
offered to foreign students. The arrangements were
excellent, and the association at that time with the
leading teachers of Austrian medicine was im-
mensely and justly famous. The facilities of the
Allgemein Krankenhaus in Vienna offered opportu-
nity for study in clinical medicine not recognized
before. To appreciate this, one need only recall
the work of Erdheiin in pathology; Stoerek in gas-
troenterology; Neumann in tuberculosis; Holzknecht
and Haudek in radiology; Kovacz, Epperling, Wenc-
kebach, and Von Jaksch in medicine; Fuchs in oph-
thalmology; Billroth in surgery; and Lorenz in ortho-
pedics. I read Dr. Tuohv’s notes written while tak-
ing the courses in Vienna, and one can glean his
delight in the opportunity for study in his chosen
field of internal medicine and also for a fine back-
ground in pathology. His devotion to the work of
Neumann and, particularly, Erdheim was a con-
stant expression in his notes. One can imagine his
jov when reading of Erdheim’s analytic approach
to his exact pathologic observations, especially in
the parathyroid gland, and the clever clinical de-
ductions of myocardial infarctions. One is impressed
by the similarity of the clinical and pathologic
approaches to the disease.

THE RETURN TO PRACTICE

On returning from Vienna, it was again a matter of
engaging in practice, and because of his preference
and Vienna training, Dr. Tnohv naturally chose
internal medicine. His Duluth associates had the
same leaning as he for group organization, and,
after a period of trial and error and defeats and
successes, these specialists organized the Duluth
Clinic in 1916. Dr. W. A. Coventry had studied
in Vienna and Dublin; Dr. O. W. Rowe, the first
pediatrician in Duluth, had studied in Vienna and
Berlin; Dr. j. A. Winter took graduate work in the
Viennese clinics, in diseases of the eye, ear, nose
and throat; Dr. T. L. Chapman, a surgeon, had
visited the clinics of London; Dr. N. L. Linneman
had adopted in his foreign studies the association of
skin and genitourinary diseases, which is now con-
sidered unreasonable; Dr. J. R. Kuth had worked
in orthopedics under Lorenz in Vienna; Dr. W.
McCabe had specialized in roentgenology; Dr. C.
Conkev’s specialty was in diseases of the eye, ear,
nose and throat; Dr. A. Collins had trained at the
Mayo Clinic. These men formed the Duluth Clinic,
which now has a staff of 40 physicians. Organization
of the clinic was not easy at first. However, the
different, forceful personalities were gradually weld-
ed into an efficient coterie of men imbued with
the zeal to practice good medicine. When new
members were added, it was soon apparent that the
carrying force was well expressed in an early pre-
amble, “that the organization is founded for the
purpose of extending to the community a good type
of practice, combined with the desire for study and
improvement in the practice of individual constitu-

496

THE JOURNAL-LANCET

ents.” For years, the elements of improvement
were fostered by an almost absolute insistence upon
attendance at all scientific meetings and weekly
staff conferences, rigid periods of vacation, regular
hours of practice, and participation in available pro-
grams. In all these activities, the examples of the
elder physicians were always present, and none had
greater foresight than Dr. Tuohy. However, some
men, as in any clinic, left to follow independent
practice. Some were not urged to continue, as dif-
ferences in personalities arose, but new and en-
thusiastic physicians were sought to fill the vacant
spots, and the early leaven continued to grow.
Younger men were urged to join the clinic and,
after a short period of general practice in the clinic,
were asked to work under the tutelage of the older
men until their abilities had been amalgamated in
the common venture. Fortunately, these additions
consisted of men with great intelligence and ambi-
tion, who ultimately proved to be excellent mem-
bers. Later, as the methods of training men in
specialties were changed, younger men were en-
gaged to serve in the different fields, which added
to the clinic the material advantages of newer de-
velopments in the ancillary sciences gained from the
excellent teaching in the various universities and
clinics throughout the eountrv. I believe that one
of the strongest attributes of successful clinics has
been the organization of men starting with equal
opportunities and developing their fields simultan-
ouslv, each ready to make sacrifices for the ultimate
goal. Dr. Tuohv and his associates felt that clinics
can develop best and function more smoothly if
all departments grow apace rather than if attention
is focused upon one individual. The martinet who
aims to lead and direct in all matters is not conducive
to sound and happy growth, and sucessful clinics
usually emerge from talents that can work in unity.

About 1920, the American Hospital Association
was organized and strove to accomplish greater im-
provement in hospital practice, just as better edu-
cational methods in the medical colleges of America
had been fostered bv the organization of the Ameri-
can Association of Medical Colleges about ten years
earlier. In 1920, the hospitals in Duluth promoted
better scientific and ethical practices among their
staffs. Anvone acquainted with the haphazard
hospital records before that time can appreciate the
results obtained through proper staff organization
and the maintenance of better records. Adequate
histories and progress notes and better and more
uniform laboratory and therapeutic standards were
initiated. The records were reviewed each month
at the staff meetings. As a result of the reorganiza-
tion, the hospital was able to offer better opportuni-
ties for internships, providing the younger men with
a proficiency which, today, is one of the great re-
wards of these efforts.

In 1921, Dr. Tuohy organized weekly clinical
pathological conferences at St. Mary’s Hospital and
encouraged physicians to procure permissions for
autopsies, therebv profoundly effecting the growth of

more accurate scientific practice. For several years,
the Duluth hospitals were among the first 10 in
the United States in the percentage of autopsies
performed. In these measures, Dr. Tuohy, with the
aid of Dr. Berdez, a pathologist from Switzerland,
played the leading role. The attendance at the
clinical conferences was excellent and participation
unique in its extent. From the first. Dr. Tuohy’s at-
tempts were stimulated bv a nonpartisan review of
all cases, naming the doctors and even, at times,
patients in order to promote an intimate discussion,
which always proved a stimulant to better work.

The work in pathology and clinical medicine was
not his only aim, but full-time roentgenologists,
pathologists, and laboratory supervisers were ap-
pointed. Newer x-rav equipment, electrocardio-
graphs, laboratory technics, medical photography,
and other ancillary developments promoted the well-
equipped hospitals of today. These advances could
not have been brought about without the constant
aid of Sister Patricia, the superintendent of St.
Mary’s Hospital, who worked unstintingly to pro-
vide all the help asked for from the Benedictine
nuns who operated the hospital.

The cooperation of other doctors from outside
Duluth was most gratifying and portrays the great
generosity of many medical friends. Dr. William
O’Brien, of the pathological department of the Uni-
versity of Minnesota, was a constant help in the
early days of organization by presenting two lecture
courses extending over several weeks in successive
vears. Dr. Leo Rigler offered similar courses in
roentgenology, teaching the newer developments in
clinical and diagnostic x-ray study. These lectures
were promoted for the sake of all practioners in
Duluth, and their faithful attendance proved their
popularity and value. The interest shown by phy-
sicans from the University and Dr. Tuohy’s friends
in the Twin Cities— friends like Drs. Henry Ulrich,
S. Marx White, Tom Peppard, and Charles Hensel—
was helpful directly or indirectly. Friendship and
stimulating interest from the Mavo Clinic served to
amalgamate a personal camaraderie in the larger
cities of the state. On one occasion, when Dr. Rowe,
the dean of the local pediatricians, was ill with
pneumonia, Dr. Tuohy called the Mayo Clinic con-
cerning the then highly extolled oxygen tent. Im-
mediately, an apparatus was sent to Duluth, and
Dr. Binger of Rochester offered to oversee its in-
stallation and operation. One of my patients, an
electrical engineer, who was a patient in the hospital
at the time, wanted to see this new mechanism at
work, and, after he examined it, he said, “If I had
invented that apparatus I wouldn’t want anyone to
know it!”

GROWTH OF SPECIAL SOCIETIES AND
OTHER DEVELOPMENTS

The University of Minnesota was growing rapidly in
the 1920’s in influence and in its excellent faculty.
Dr. Tuohy, Louis Wilson of Rochester, and Dr.
Theodore Bratrud of Warren, Minnesota, were ap-

NOVEMBER 1958

497

pointed to an alumni advisory committee and served
at the time the Mavo Clinic was incorporated into
the University faculty. The affiliation at first was
more or less acrimonious but finally evolved into a
very successful union of forces, tending to unify the
University’s more academic work and its research
with the experiences of a great clinic.

In the first World War, Dr. Tuohy served as a
heart board examiner at Camp Douglas, working for
a time with Dr. Dan Glomseth of Des Moines, a
conspicuous worker in cardiac physiology. This
work was in conformity with Dr. Tuohv s love for
clinical cardiology and provoked a continuous in-
terest in that specialty.

The American College of Internal Medicine was
organized shortly thereafter, and Dr. Tuohy was a
charter member, serving for sixteen years as gover-
nor for Minnesota on the National Board of Gover-
nors for the society.

In Minnesota, he was one of the founders of the
Minnesota Society of Internal Medicine and the
Minnesota Society for the Study of Diseases of the
Heart and Circulation and was a persistent and
vocal proponent of their aims and an active partici-
pant in their programs. Dr. Tuohv has also received
many distinctions, a verv notable one from his alma
mater, the University of Minnesota, which bestowed
upon him the distinguished service medal for his
outstanding work for the University and his success
as a prominent graduate. He was elected president
of the St. Louis County Medical Society and, later,
was elected president of the Minnesota State Medical
Association.

In his civic pursuits, he was elected governor of
the ninth district of Rotary International and, with
his son, journeyed to Vienna where he was a dele-
gate to the international convention. Although happy
to return to his former scene of study, he sadly
noted the decline of that which had been to him an
outstanding period in medical study. After leaving
Duluth in 1956, he became a postservice member of
Rotary in an enjoyable confraternity of former mem-
bers in his new home in Santa Barbara.

Travel has always been a minor obsession with
Dr. Tuohv, not merely for the entertainment offered
but also for the opportunity to satisfy his interest in
other cultures. An equally eager traveler, Mrs. Tuohy
always accompanied him. His experiences as a cos-
mopolite fostered a deep love for art, music, history
and politics, and his discerning mind brings forth
delightful entertainment when he tells of these
interests. His pleasure in travel was illuminated by
the friendships he cultivated in his journeys to
Europe and Mexico and his extensive travels in our

own country. His pervading sense of humor enabled
him to classify his experiences in their proper value.
On one occasion, after he had been in Mexico Gitv
for two weeks, he was asked what he thought of the
Mexican political situation. He answered that he
was hardly in a position to judge a political situa-
tion in so short a time, since the natives of Mexico
seemed to be confused themselves in regard to
their political picture! On one occasion, while
traveling in Jamaica, a prowler stole his trousers by
lifting them through the transom in the room of his
hotel. Upon his return, he said that evidently some
people of his acquaintance seemed more interested
in the fate of his trousers than in the opportunity
for intellectual growth that he might have indulged
in! His humor, so constantly a part of him, always
was an asset in public and professional appearances,
and his discussions were anticipated with enjoyment.
His sallies of wit were not always one-sided, and,
when thev were in defense of himself, he was al-
ways gracious. On one occasion, the name of Ohara
arose as one of the discoverers of tularemia, and
he burst forth with a eulogv of the Irish in the fore-
front of medicine. When told that Ohara happened
to be a Japanese, a “slow burn” came over him,
followed at once by a gleeful acceptance of the cor-
rection! He was always a severe critic in medical
forensics. However, as his many medical friends can
well remember, his criticism was always pointed and
logical but also with an acknowledgement of similar
propensities in others. It was in this way that he
conducted his clinical pathological conferences, al-
ways rendering them sprightly and never dull. Visi-
tors were frequent from other centers, and their
participation was always sedulously encouraged and
opportunity was given for the presentation of a
speaker’s “tour de force.”

The death of Mrs. Tuohv was a grievous shock.
Dr. Tuohv had witnesed the suffering she endured
for many months with a postherpetic neuralgia,
which undoubtedly aggravated a previous hyperten-
sion. He went through a period of bereft loneliness
which was hard to endure and sad to witness. A
few years later, he and Mrs. Alice Lvons Tweed
were married, and their similar love for travel and
experience as well as compatibility of other interests
have developed into a companionship which is a
joy for their friends to witness. They are now living
in Santa Barbara, California. Dr. Tuohy’s ardor for
visiting hospitals, clinics, and medical meetings still
persists, and, on his return to the clinic which he
helped to form, there is always an occasion for a
recital of his experiences and observations in medi-
cine, travel, and contact with other people.

498

THE JOURNAL-LANCET

CdHCCt Editorial

Nursing Home Care

WITHIN THE PAST few months, there has been
formed The Joint Council to Improve the
Health Care of the Aged by the American Medical
Association, the American Hospital Association, and
the American Nursing Home Association. This Coun-
cil has as its primary objective the improvement of
care of the aged and chronically ill. In any consid-
eration of such care, the need for high quality nurs-
ing homes becomes verv evident. Prior to the for-
mation of this Council, a number of meetings be-
tween representatives of the ANHA and the AM A
had taken place. There were also meetings between
representatives of the AHA and the ANHA to which
AMA was invited and attended. The AMA has been
represented by various members of the committees
of the Council on Medical Service. These so-called
liaison meetings were extremely productive and in-
formative in that it was apparent that the three
groups had basically the same objective — to improve
the quality of care in nursing homes. In Febru-
ary 1958, the United States Public Health Service
sponsored a National Conference on Nursing Homes
and Homes for the Aged in Washington. Following
this, the American Hospital Association held a simi-
lar conference in Chicago in May. The AMA had
active representation at both conferences.

There are presently in existence approximately
25,000 nursing homes with approximately 450,000
beds. Of course these homes range from the very
good to the very bad and give a wide range of serv-
ices. In most states, they are subject to license
usually by the State Health Department and, in a
few states, through the Department of Public Wel-
fare. It is the avowed purpose of the ANHA to
make every effort to improve the physical facilities
and the care in them. They feel, and rightly, that
they must have a lot of assistance from not only the
organized medical profession but also from individual
doctors to achieve this objective.

At the present time, there are two definite pro-
grams being developed. The first program is being
done by the ANHA and consists of a pilot classifica-
tion study of all the homes in the state of Illinois.
The ultimate purpose would be to acquire sufficient
information which might eventually lead to a sys-
tem of accreditation comparable to that used for
the hospitals. It has been felt that there is lacking
a definite standard for medical care and medical

supervision of nursing homes so that a set of “guides”
is being developed primarily by the representatives
of the Council on Medical Service. The guides cur-
rently being proposed will be rather broad in scope
and will suggest that ( 1 ) each patient should have
the care of an individual physician and (2) each
nursing home should have some doctor who is pri-
marily responsible for the general care in the home.
In the case of a large home, there might be a staff
organization similar to that of a general hospital,
whereas a smaller home might well be served by
a single physician.

In the course of discussions on this subject, it
became readily apparent that some doctors did not
evidence sufficient interest in the over-all improve-
ment of care in a nursing home. We believe that, in
any area where there is a nursing home or homes,
it would be in the best interests of the doctors, the
patients, and the home operators if physicians would
take an active interest and exert leadership in im-
proving the quality of not only medical but of gen-
eral care.

At the National Conference on Nursing Homes
and Homes for the Aged, it was suggested that
facilities be classified as follows:

A. Residential facilities

B. Personal care facilities

C. Nursing care facilities

D. Comprehensive services facilities

The report goes on to define the type of services
which would be rendered in each type of facility.

Perhaps the greatest difficulty encountered bv
those who wish to operate high-grade nursing homes
has been in the field of finance. It has been difficult
to secure financing for construction of modern build-
ings, and of course there is the difficulty of financing
the operation of the home. Most nursing homes are
proprietary and hence not eligible for Hill-Burton
funds. Following discussions between the various
groups, the AMA has approved the principal of long-
term, low-interest loans for the building of nursing
home facilities guaranteed by the federal govern-
ment. This has been designated as an FHA type of
program. Testimony has been entered in two con-
gressional hearings by representatives of the AMA
approving this type of loan. Providing sufficient cur-
rent income to operate the home satisfactorily in-
volves consideration of the entire problem of proper

NOVEMBER 1958

499

support of the nonworking population. It is esti-
mated that approximately 35 per cent of older per-
sons have sufficient means of their own to care for
themselves in a satisfactory manner. However, in-
creasing numbers of persons are dependent on vari-
ous forms of governmental assistance. Frequently,
it is in this area that operators of homes find them-
selves held down to such a low income that they are
unable to provide the best type of services. Welfare
boards involved in public assistance programs are
required to keep their payments for these services
as low as possible, and in many instances they are
below actual cost. At the present time, there does
not seem to be any remedy for the rigidity of gov-
ernment programs. The possibility of providing some
type of insurance for this care is being explored, but
it can readily be understood that great difficulties
would be encountered in working out a suitable in-

surance plan. Naturally it would be best if each in-
dividual or his family were able to provide sufficient
funds for their care in old age and times of sickness.
Such a situation does not seem to be developing cur-
rently.

Our national organizations are all vitally interested
in and actively concerned with the problems in-
volved in providing a better quality of care for the
aged and chronically ill. It is to be hoped that every
doctor will take an active interest in this program
and contribute both his time and medical knowledge
wherever it will do the most good.

Willard A. Wright, M.D.
Chairman, Committee on Medical and
Related Facilities,

Council on Medical Service,

American Medical Association,
Williston, North Dakota

Gynecologic and Obstetric Pathol-
ogy, by Emil Novak, M.D., and
Edmund Novak, M.D., ed. 4,
1957. Philadelphia: W. B. Saun-
ders Co. $14.00.

This textbook, which has become a
standard for students of obstetrics
and gynecology, has come out in a
new edition since the passing of the
senior author.

In this edition, recent literature
has been drawn on liberally. Re-
ferences extend through 1956. There
is new material on cervical mucous
changes in menstruation cycles and
during pregnancy as well as on ex-
foliative cytopathology.

Color is used quite effectively in
some parts of the book. Other ill-
ustrations are well done, and the
printing is excellent. The text lends
itself to easy reading, and no library
is complete without this excellent
book.

Reuben F. Erickson, M.D.

Roentgenology of the Chest, edited
by Coleman B. Rabin, M.D.
Editorial committee: Benjamin M.
Gasul, M.D., Burgess L. Gordon,
M.D., J. Winthrop Peabody, Sr.,
M.D., Leo G. Rigler, M.D., Is-
rael Steinberg, M.D., and Har-
old G. Trimble, M.D., 1958.
Springfield, Illinois: Charles C

Thomas, 484 pages. $19.50.

The stated purpose of this book is
“to present roentgenology of the
chest to the roentgenologist from
the clinical standpoint, and to the

clinician from the radiological point
of view.” To fulfill this pledge, a
galaxy of 50 authors, both radiolo-
gists and chest physicians, have
been recruited and have contributed
chapters on subjects of special in-
terest to them. One of the pleasant
consequences of the stature of the
contributors is that the text is alive
with positive opinions. Parentheti-
cally, it should be noted that the
book is further enlivened when the
diverse opinion is presented with the
same degree of positivity.

Approximately 300 pages are de-
voted to the lungs; 50 pages to the
pleurae, diaphragm, and medias-
tinum; and 100 pages to the heart.
As would be expected from this dis-
tribution, the pulmonary subjects
are dealt with in the most detail.
The chapter divisions in the pul-
monary section are of interest. While
the first chapters confine themselves
to descriptions of such diseases as
tuberculosis, fungous infections, and
so forth, the latter part of the hook
covers such subjects as special signs
in chest roentgenology, isolated nod-

ular shadows, and linear shadows.
This dual system of chapter division
results in an emphasis on the clini-
cal viewpoint in the first portion of
the book and an emphasis on the
radiologic point of view in the
latter.

Chapters on the normal findings
in the chest are brief hut well-
illustrated. The over-all quality of
the illustrations is excellent as are
the explanatory notes which ac-
company them.

This book will interest all phy-
sicians who wish authoritative but
nonencyclopedic information to sup-
plement their knowledge of chest
diseases.

John R. Amberg, M.D.

Lens Materials in the Prevention of
Eye Injuries, by Arthur H. Kee-
ney, M.D., 1957. Springfield, Illi-
nois: Charles C Thomas, 73 pages.
$3.50.

The purpose of this monograph is
stated by the author in Chapter 1
as follows: “(1) to analyze the

tecnical development of safety lens
materials useful in spectacles and
goggles to prevent mechanical in-
jury, (2) to study experimentally
the characteristics of safety lens
materials, and (3) to formulate
specific indications and contraindica-
tions for the various materials.”

The 7 chapters of the book are:
1. Introduction and Purposes, II.
Early Steps in Technical Develop-
ment of Protective Lens Material
(Continued on page 32A)

500

THE JOURNAL-LANCET

eeds support, too...

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iroughout lactation

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ter future health for her and her baby. A single
NATABEC Kapseal each day provides all the
vitamins and minerals the gravida or nursing
mother needs to supplement a well-rounded diet.

each NATABEC Kapseal contains:

Calcium carbonate 600 mg.

Ferrous sulfate 150 mg.

Vitamin D (10 meg.) 400 units

Vitamin Bi (thiamine) mononitrate. . .. 3 nig.

Vitamin B2 (riboflavin) 2 mg.

Vitamin B12 (crystalline) 2 meg.

Folic acid 1 mg.

Synkamin® (vitamin K) (as the hydrochloride) 0.5 mg.

Rutin 10 mg.

Nicotinamide (niacinamide) 10 mg.

Vitamin Be (pyridoxine hydrochloride) 3 mg.

Vitamin C (ascorbic acid) 50 mg.

Vitamin A (1.2 mg.) 4,000 units

Intrinsic factor concentrate 5 mg.

dosage As a supplement during pregnancy and throughout
lactation, one or more Kapseals daily. Available in bottles of
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BOOK REVIEWS

( Continued from page 500 )
and the Concept of Preventing Eye
Injuries, III. The Development of
Current Safety Lens Materials, IV.
Experimental Studies with Protec-
tive Lenses, V. Relative Merits of
Plastic Lenses, VI. Indications of
Contraindications of Various Lens
Materials, and VII. Summary and
Conclusions.

In this monograph, Dr. Keeney
presents the history of protective
spectacles, largely for industrial pur-
poses. The second chapter gives a
very interesting discourse on the
development of safety glass. It is
difficult for us at this time to imagine
people not being safety glass con-
scious. However, this development
was slow in coming. Much work has
been done to develop the safety
spectacle concept. At the same time,
materials for frames, lenses, and so
forth had to be invented or develop-
ed, which would allow the workman
to see and, at the same time, pro-
tect him.

Although this monograph may ap-
pear on the surface to be rather
technical, it is really very interesting
reading. The good and bad points
of the various types of safety glass
are discussed as well as where and

why different types of safety spect-
acles should be used.

The book is printed on smooth
paper and is fairly large and read-
able. The excellent illustrations are
all black and white.

This small monograph fills an un-
usual place in the library of the
practicing ophthalmologist as well
as the manufacturers and dispensers
of safety eye wear. It gathers to-
gether and sums up a great deal of
material which is not, to these re-
viewers’ knowledge, readily avail-
able. The ophthalmologist or the
ophthalmic dispenser will be able
to make proper recommendations at
a glance to any industrial concern
wishing to introduce an eye safety
program. These reviewers feel that
this monograph is a very worthwhile
contribution to the current body of
ophthalmic literature.

Francis M. Walsh, M.D.

Leon D. Garris, M.D.

•

Pica, by Marcia Cooper, Sc.D.,
1957. Springfield, Illinois: Charles
C Thomas, 114 pages. $3.75.

This is a very extensive survey of
every aspect of the little known but
fascinating subject or pica done in
a carefully organized fashion. A his-

toric survey of pica as recorded in
the earliest literature from ancient
and medieval times down through
the present is presented in a de-
tailed, interesting account. A study
of pica in domestic animals is in-
cluded.

Laboratory experiments of self-
regulatory functions in animals and
young children are cited as a possi-
ble analogous situation in which
pica is practiced to satisfy intrinsic
physiologic needs. A complete
chemical analysis of edible earth
and its possible contribution to
human and animal nutrition is made.

The study on pica of 784 pre-
school children was undertaken by
the author. The incidence of pica,
its distribution by sex and race, its
various forms, and its relationship to
various factors, such as intelligence
and the socioeconomic status of the
family, were determined. There is
considerable speculation concerning
the various possible factors, but no
definite conclusions are made from
this study.

The book serves to bring the sub-
ject of pica to tbe attention of prac-
ticing physicians, particularly the
pediatrician and obstetrician.

Ruth Hase, M.D.

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Journal

J III l-^ I SERVING THE MEDICAL PROFESSION OF MINNESOTA,
I V W'W V NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

Vaccinia Virus Immunization of Patients with
Recurrent Herpes Simplex Virus Infections

T. E. EYRES, M.D., and E. C. PIRTLE, Ph.D.

Vermillion, South Dakota

IT IS A FAIRLY WELL- ACCEPTED FACT that IllOSt

primary infections with the virus of herpes
simplex occur in early childhood and at a time
when no homologous neutralizing antibodies
are present. The majority of initial encounters
with this virus go unnoticed, but a number of
young susceptible children experience a very
pronounced herpetic stomatitis accompanied by
systemic reactions.1 Following either of these
two extremes in response to the initial experi-
ence with the virus of herpes simplex, neutraliz-
ing antibodies can be detected in the blood.
Although fluctuations in antibody levels may be
detected in herpetic sera from time to time, the
neutralizing capacity is probably maintained for
life.2’3

The virus of herpes simplex is a relatively suc-
cessful parasite. It finds new and frequent hosts
among human beings, the majority in the form
of subclinical infections. Except in the less com-
mon involvements, such as eczema herpeticum
and herpes encephalitis, tissue damage to the
host is minimal. Although neutralizing antibodies
are present after the first natural experience with
this virus, such immunity is ineffectual in com-
bating the recurrence of lesions in herpetic pa-
tients. Thus, it appears that the herpes virus is
well adapted for survival in its human hosts.

t. e. eyres is professor of public health in the School
of Medicine, State University of South Dakota, e. c.
pirtle is affiliated with the University's Department
of Microbiology and Public Health.

Even though a relatively large percentage of
individuals actively acquire and maintain anti-
herpes immunity early in life, a certain number
experience numerous recurrent attacks by this
viral agent. When the initial lesions occur in the
buccal mucosa, subsequent lesions generally de-
velop around the mouth or face.1 In women,
if the primary area of involvement occurs on
the genitalia rather than the buccal mucosa, the
lesions are usually observed on the labia pu-
dendi and vaginal mucosa, with recurrences
most often on the former. Occasionally, the pri-
mary herpetic lesion occurs on the cornea, com-
monly resulting in a dendritic keratitis. Recur-
rent lesions upon the cornea often result in cu-
mulative impairment of vision.4 Symptoms in
secondary herpes attacks are most frequently
restricted to the site of lesion activity, and sys-
temic effects are minimal or absent.

In considering recurrent attacks by the virus
of herpes simplex, two points should be empha-
sized. First, recurrent lesions tend to appear in
close proximity to the area of primary involve-
ment. This suggests that the pathogenesis of the
primary lesion induces some critical alteration
in certain host cells, for example, hypersensi-
tization. Second, because neutralizing antibodies
are present prior to the appearance of recurrent
lesions, it appears logical to conclude that en-
dogenous (latent) virus rather than exogenous
is responsible for the recurrent episodes. In
support of this conclusion, one need only refer
to some of the recent evidence and reports3 on

the potentialities of noninfectious stages of im-
mature virus (provirus) present in host tissue
and how these may be stimulated to undergo
complete cycles of viral replication to yield ma-
ture infective virus.

Renewed activity of latent herpes virus may
be stimulated in different patients bv a number
of factors, such as direct trauma, sunburn, fe-
brile illnesses, menstruation, and emotional stress.
With the exception of direct trauma, it would
appear that increased metabolic processes which
accompany the other factors could “trigger” the
herpes virus into increased activity. Whether
there is a common basis for these factors, for
example, moderate to pronounced elevation of
body temperature, the end result in the chronic
herpetic patient is the same, that is, periodic
appearances of new lesions. Three possibilities
have been considered as sites for herpes virus
to remain dormant between periods of clinical
activity:6 (1) in epithelium of the affected area,
(2) in terminal nerve endings in the affected
sites, and (3) in ganglia associated with fibers
leading to terminal nerve endings.

Although immunization of herpetic patients
with vaccinia virus has been carried out by
others,7-9 it was desired to evaluate this method
of therapy in a cross section of patients, using
high-potency vaccine, and to follow their clinical
progress over a period of time. It was hoped
that some conclusion could be reached concern-
ing whether vaccinia virus does exert a blocking
effect upon the virus of herpes simplex.

MATERIALS AND METHODS

Patients. The distribution of men and women
among the 30 subjects in this investigation was
about equal. Ages ranged from 13 to 61 years.
On the basis of the case history, the frequency
and degree of recurrent herpes were graded as
mild, moderately severe, or severe. The lesions
were distributed primarily about the mouth and
face and involved from 1 to 10 cm. of surface
area.

Isolation of virus. The clinical diagnosis of
recurrent herpes simplex was confirmed by iso-
lating the etiologic virus in embryonated eggs
from the vesicular fluids from all but 5 of the
patients studied. The isolated viruses were iden-
tified by virus neutralization in embryonated
eggs with known antiserum prepared in immu-
nized rabbits.

Vaccinia virus for immunization. The vaccine
virus was the standard calf-lymph virus used in
the routine immunization against smallpox. The
vaccine was delivered packed in dry ice and
was kept at —20° C. until needed.

Procedure of immunization. If a patient gave
no definite evidence of having been immunized
against smallpox, an initial immunization was
given and the primary response allowed to re-
gress for three weeks to one month before addi-
tional immunizations were given. A series of 7
immunizations was then performed at weekly
intervals. No untoward reactions were observed
in any of the patients undergoing multiple im-
munization with vaccinia virus. However, herpes
zoster did develop in 1 patient after receiving
the third of 3 additional immunizations. In no
instance was a patient told that the vaccinia im-
munizations would stop the recurrent attacks of
herpes. On the other hand, patients were told
that an honest appraisal of the method was be-
ing attempted and that they might not experi-
ence improvement after receiving the immuniza-
tions.

Follow-up contacts. To determine the status
of recurrent attacks since completion of the vac-
cinia immunizations, local patients were contact-
ed either in person or by phone, and the others
were contacted by mail.

RESULTS

In our follow-up contacts, essentially all of the
30 patients with recurrent herpes simplex ex-
perienced relatively good improvement follow-
ing multiple vaccinia immunizations.

Table 1 presents a summary of information
and results of this investigation. Two of the 30
patients experienced no further recurrences, 17
experienced marked improvement, 10 showed
improvement, and 1 did not reply. Those indi-
cated as showing marked improvement experi-
enced only a rare recurrence after their immu-
nizations, and these were very mild and in-
volved much less surface area. Furthermore, the
lesions in these infrequent recurrences were defi-
nitelv of an abortive nature, seldom persisting
for longer than twenty-four to thirty-six hours.
Those patients indicated as showing improve-
ment likewise experienced a longer interval be-
tween recurrences. Their lesions were definitelv
less severe and the transition more rapid than
before vaccinia immunizations. Two patients,
cases 16 and 27, received 3 and 5 additional
vaccinia immunizations, respectivelv.

DISCUSSION

Bedson and Bland1" found no immunologic cross-
ing between the viruses of herpes simplex and
vaccinia in their experiments on guinea pigs.
If there is no cross-immunizing abilitv between
these two viruses, wherein is an answer sought
to why many recurrent herpetic patients experi-

502

THE JOURNAL-LANCET

TABLE 1

VACCINIA IMMUNIZATION IN THE TREATMENT OF RECURRENT HERPES SIMPLEX

Patient

Age

Recurrence of
herpes

Post-treatment

observation

(months)

Status at
final

observation

1

27

Severe

72

No further lesions

2

24

Severe

39

No reply

3

21

Severe

38

Improved

4

20

Moderately severe

38

Marked improvement

5

28

Moderately severe

37

Marked improvement

6

20

Moderately severe

37

Improved

7

27

Moderately severe

36

Improved

8

18

Moderately severe

31

Marked improvement

9

43

Moderately severe

29

Marked improvement

10

22

Moderately severe

29

Marked improvement

11

30

Severe

27

Marked improvement

12

23

Moderately severe

26

Marked improvement

13

13

Moderately severe

26

Improved

14

50

Moderately severe

25

No further lesions

15

20

Moderately severe

25

Improved

16

45

Moderately severe

23

Marked improvement

17

26

Moderately severe

22

Marked improvement

18

22

Mild

22

Improved

19

20

Severe

21

Marked improvement

20

22

Severe

21

Marked improvement

21

23

Moderately severe

20

Improved

22

19

Moderately severe

19

Marked improvement

23

27

Moderately severe

18

Marked improvement

24

23

Moderately severe

18

Marked improvement

25

24

Moderately severe

14

Improved

26

20

Moderately severe

14

Marked improvement

27

61

Severe

12

Marked improvement

28

20

Severe

10

Marked improvement

29

20

Mild

8

Marked improvement

30

19

Moderately severe

6

Improved

ence improvement after multiple immunizations
with vaccinia virus?

Blank and Brody'1 reported that they achieved
beneficial results in patients with recurrent at-
tacks of herpes simplex by using psychotherapy,
and they obtained variable results with multiple
vaccinia immunizations. Their patients were suf-
fering from emotional instabilities, which, at the
same time, probably made them physiologically
unstable. We are of the opinion that physiologic
imbalance, with concomitant metabolic altera-
tions, may serve as an inciting agent in recur-
rent herpes, vide infra. However, we are not in
agreement with “ . . . , other than removing or
modifying excitants, all forms of therapv owe

their effectiveness to their psychological sug-
gestive effect upon the patient ”'2

In an article by Roxburgh,13 an excerpt from
a letter by Edward Jenner, dated October 25,
1804, and taken from Baron’s Life of Jenner
reads: “The further I go on with vaccination,
the more I am convinced that the great and
grand impediment to the correct action of the
virus on the constitution is the coexistence of
herpes In still another article regarding

some older observations, Findlay14 refers to
Montaigne, who, in 1580, stated that “one ill
cureth another;” to Quier, who, in 1780, reported
that smallpox was invariably a mild disease in
children with secondary yaws; to Winterbottom,

DECEMBER 1958

503

who, in 1803, reported that some African tribes
of the Sierra Leone region treated chronic ring-
worm by inoculating the affected area with her-
petic material; and to Archer, who, in 1809, re-
ported that vaccination ameliorated the course
of whooping cough in children. Recent experi-
mental evidence15 has shown that vaccinia virus
induces resistance in mice to an otherwise fatal
infection with Hemophilus pertussis. Herrmann
and associates16 have demonstrated that tonic
convulsions induced in mice by vaccinia virus
can be prevented by treatment with heated in-
fluenza virus. In the examples just mentioned,
implications are noted of “interference” between
virus and spirochetes, fungus and virus, virus
and bacteria, and, finally, virus and virus. In-
deed, numerous examples of interference be-
tween related and unrelated animal viruses have
been known for several generations.17 In many
of the known examples of viral interference, the
exact mechanism of the phenomenon is not un-
derstood. It seems clear, however, that in the
cases of unrelated viruses, the blocking effect of

one virus by another is not based upon the de-
velopment of specific antibodies against the
virus being blocked.

However vague the phenomenon of viral in-
terference may appear with regard to clinical
improvement of patients with recurrent herpes
simplex following multiple immunizations with
vaccinia virus, we believe that vaccinia virus
does exert an interference-like or partial block-
ing effect on the virus of herpes simplex.

SUMMARY

The cases of 30 patients with recurrent herpes
simplex who were treated with multiple vaccinia
immunizations are reported. Essentiallv all pa-
tients showed clinical improvement after treat-
ment. The improvement is believed to be the
result of some form of viral interference.

Tliis investigation was supported by a research grant,
E-733, from the National Institutes of Health, Public
Health Service. The virus vaccine was provided by
Lederle Laboratories Division of American Cyanamid
Co., Pearl River, New York.

REFERENCES

1. Si.avin, II. B.: Clinical ramifications of infections caused by

virus of herpes simplex. M. Clin. North America 35:563, 1951.

2. Jawetz, E., and Coleman, V. R.: Studies on herpes sim-

plex virus; neutralization of egg-adapted herpes virus by hu-
man sera in ovo. J. Immunol. 68:645, 1952.

3. Jawetz, E., Allende, M. F., and Coleman, V. R.: Studies
on herpes simplex virus; level of neutralizing antibodies in
human sera. J. Immunol. 68:655, 1952.

4. Gallardo, E.: Primary herpes simplex keratitis; clinical and

experimental study. Arch. Ophth. 30:217, 1943.

5. Walker, D. L., Hanson, R. P., and Evans, A. S.: Latency
and Masking in Viral and Rickettsial Infections (Symposium).
Minneapolis: Burgess Publishing Company, 1958.

6. Findlay, G. M., and MacCallum, F. O.: Recurrent trau-

matic herpes. Lancet 1:259, 1940.

7. Foster, P. D., and Abshieh, A. B.: Smallpox vaccine in

treatment of recurrent herpes simplex. Arch. Dermat. & Sypli.
36:294, 1937.

8. Woodburne, A. R.: Herpetic stomatitis (aphthous stoma-

titis). Arch. Dermat. & Syph. 43:543, 1941.

9. Schiff, B. L., and Kern, A. B.: Multiple smallpox vaccina-
tions in treatment of recurrent herpes simplex. Postgrad. Med.
15:32, 1954.

10. Bedson, S. P., and Bland, J. O. W.: On supposed relation-
ship between viruses of herpes febrilis and vaccinia. Brit. J.
Exper. Path. 9:174, 1928.

11. Blank, H., and Brody, M. W.: Recurrent herpes simplex;

psychiatric and laboratory study. Psychosom. Med. 12:254,
1950.

12. Blank, H., and Rake, G.: Viral and Rickettsial Diseases of
the Skin, Eye and Mucous Membranes of Man. Boston: Little,
Brown & Co., 1955, p. 67.

13. Roxburgh, A. C.: Pathological relationships of herpetic dis-
eases from clinical standpoint. Brit. J. Dermat. 39:13, 1927.

14. Findlay, G. M.: Non-specific resistance against virus infec-

tions. J. Roy. Microscop. Soc. 68:20. 1948.

15. Dalldorf, G., Cohen, S. M., and Coffey, J. M.: Resist-

ance induced by vaccinia virus to pertussis infection in mice.
J. Immunol. 56:295, 1947.

16. Herrmann, E. C., Jr., Anderson, O. F., and Harkins, A.:
Tonic convulsions induced in mice by vaccinia virus and their
prevention by heated influenza virus. Proc. Soc. Exper. Biol.
& Med. 89:536, 1955.

17. Lennette, E. H.: Interference between animal viruses. Ann.
Rev. Microbiol. 5:277, 1951.

504

THE JOURNAL-LANCET

Toxic Drugs and Deafness

ROGER E. WEHRS, M.D.
Tulsa, Oklahoma

The toxic effect that some drugs exercise
on the hearing acuity has long been recog-
nized. It is known that tinnitus and deafness
can be produced by overdosage of the salicylates
or quinine. However, the best known offenders
in this field are streptomycin and its sister drug,
dihydrostreptomycin.

The purpose of this paper is to review the lit-
erature on the subject in an attempt to deter-
mine the relative toxicity of the various drugs
and their site of pathology on the organ of
hearing.

As early as 1922, Pohlman and Kranz1 were
experimenting in St. Louis with the effect of
quinine, aspirin, and other salicylates on the
hearing mechanism. They were handicapped in
that they were able to only crudely measure
their subjects’ hearing. They concluded that
although these drugs produced a definite de-
crease in hearing, recovery occurred in approxi-
mately twenty -four hours.

In 1936, Coveil- performed an extensive study
on the effect of salicylates and quinine on the
cochlea of rats. He determined that both drugs
altered the mitochondria in cells of the stria
vascularis and external hair cells. He believed
that the salicylates were direct protoplasmic-
poisons.

After similar studies, Falbe-Hansen3 found
hvpertonic degeneration in the cochlear duct.
He then formulated the theory that salicylates
and quinine produce increased secretion of the
labyrinthine fluids and, thus, pressure on the two
fenestra. The increased pressure produces a hear-
ing loss and accounts for the symptoms. He also
conducted detailed clinical studies with both
quinine and sodium salicylate. In his human sub-
jects, the drugs produced aural symptoms, in-
cluding deafness and vertigo. However, even
with massive doses, no permanent loss was dem-
onstrated; the hearing returned to normal in
twenty-four to thirty-six hours.

roger e. wehrs was formerly affiliated with the
Department of Otorhinolaryngology at the Univer-
sity of Kansas School of Medicine and is now en-
gaged in private practice in Tulsa, Oklahoma.

Waltner,4 writing in 1955, presented a case
of a 25-year-old patient who, following a tonsil-
lectomy, took a total of 200 5-gr. aspirin tab-
lets over a period of six days.

An audiogram revealed a bilateral perceptive
deafness of 40 to 50 decibels with complete re-
cruitment. Caloric testing was normal, and com-
plete recovery occurred in seven days, with the
audiogram returning to normal. Because of the
rapid recovery, Waltner feels that this entity is
due to increased pressure in the labyrinth and,
thus, is similar to Meniere’s disease.

Following Waksman’s discovery of streptomy-
cin in 1944 and its widespread use in cases of
tuberculosis, it was soon realized that this was
a drug of not only great curative powers but of
great selective toxicity as well. Most of the lit-
erature agrees that streptomycin has a selective
effect on the vestibular function, though, in some
instances, it may also cause hearing loss. Di-
hydrostreptomycin, on the other hand, is re-
ported to impair hearing primarily and to fre-
quently destroy the vestibular function as well.

Barr and associates,5 in 1949, reported that
approximately 40 per cent of a series of pa-
tients who had received a total dosage of over
20 gm. of streptomycin showed vestibular nerve
lesions, but the risk was small in daily doses
of 0.5 to 1 gm. provided the total dosage did
not exceed 60 gm.

Glorig and Fowler,6 in 1947, stressed vestibu-
lar toxicity in treatment with streptomycin. Of
23 patients treated for more than two months,
hearing was normal in all except 1, but only 3
had normal labyrinths.

Since 1949, a number of authors have report-
ed hearing losses following dihydrostreptomycin
therapy. The doses have varied considerably,
and the hearing loss has had its onset either at
the time of or up to four months after treatment.
The damage ranged from moderate hearing im-
pairment to total deafness.

Falkenfleth,7 in 1952, found a hearing loss in
10 per cent of patients who had been treated
with dihydrostreptomycin over long periods of
time. Liden8 found that of 10 patients treated
with streptomycin, hearing injuries developed in

DECEMBER 1958

505

4 and the vestibular organ was damaged in 7,
while in those treated with dihydrostreptomycin,
the corresponding figures were 8 and 5.

In a further study of 150 patients with pulmo-
nary tuberculosis who received 2 or 3 gm. of
dihvdrostreptomvcin daily for at least three
months, Glorig0 reported hearing losses in 31
per cent. Total deafness developed in one-
fourth of the patients and impaired hearing
ranging between 30 to 80 decibels in the re-
mainder. Glorig concluded that streptomycin
is the drug of choice, since dihvdrostreptomvcin
causes both a loss of hearing and vestibular
nerve damage, lie emphasized the fact that
deafness constitutes a considerably greater han-
dicap than a disturbance of balance.

Nilsson and Bleck9 further urge the use of
plain streptomycin. The only exceptions would
be in cases of an allergy or bacterial resistance
to streptomycin and not to dihydrostreptomycin.
Neither of these conditions are common. They
also caution against the use of combination anti-
biotic preparations. Most of these contain peni-
cillin and dihvdrostreptomvcin or mixtures of
streptomycin and dihvdrostreptomvcin with the
penicillin. There seems to be no reason to use
or encourage the use of dihvdrostreptomvcin
either alone or in combination.

In an effort to localize the focus of attack of
streptomycin, Liden performed a clinical inves-
tigation utilizing the recruitment phenomenon.
Through this procedure, he hoped to determine
whether the damage was localized in the end
organ or the nervous pathways. Thus, complete
recruitment placed the lesion in the cochlea,
while absence of this phenomenon pointed to a
retrocoehlear lesion.

He found complete recruitment in all patients
treated for pulmonary tuberculosis with strepto-
mycin or dihydrostreptomycin. He feels that the
presence of recruitment in such cases lends
weight to the view founded on animal experi-
ments that damage due to streptomycin primarily
affects the sensory organ. However, in a group
of children who had had tuberculosis meningitis,
the recruitment phenomenon was absent in 3 of
the patients. These cases were thought to repre-
sent retrocoehlear lesions and have been inter-
preted as being caused by the meningitis.

Another drug which has been found to have
a toxic effect on the hearing is neomycin, and it
has been responsible for many cases of deafness
following its experimental use.

Risker10 and associates did a beautiful piece
of work in Sweden on the toxic effect of the
mycins on experimental animals. They found
that neomycin exerts a selective toxic effect on

the acoustic function and produced complete
deafness by destroying the organ of Corti. De-
struction of the acoustic tubercle was also noted
where a number of ganglion cells were de-
stroyed. However, when used topically in ani-
mals with artificial perforations in their ear-
drums, no toxic effect was noted. Because of its
pronounced nephric as well as cochlear toxicity,
neomycin has been abandoned as a systemic an-
tibiotic.

Risker and associates performed similar ex-
periments with streptomycin and found that the
histologic findings did not compare in severity’
to the clinical findings. Even in the guinea pig
with abolished vestibular function, there was no
change in the macula of the utricle, saccule, or
cochlea. However, there were swollen ganglion
cells with ill-defined contours but visible nuclei.
Thev concluded that the mycins attack the pe-
ripheral sensory cells as well as the central gan-
glion cells but that the function of these cells
may be abolished without demonstrable histo-
logic change.

These authors further state that selective tox-
icity of the mycins is well known, but the af-
finity of these drugs for the vestibular and coch-
lear systems is still unexplained and the mech-
anism of destruction is entirely unknown. How-
ever, of great clinical significance are the facts
that the destruction is irreversible and that so
far there is no way of preventing damage if the
drug is used.

In contrast to this viewpoint, Ozaki11 report-
ed in 1957 that by the intravenous administration
of vitamin Bi (thiamine), he has prevented or
even improved the hearing loss due to strepto-
mycin toxicity. He stresses the importance of
discontinuing streptomycin treatment at the first
sign of toxicitv and before the administration
of vitamin IT is begun. He administers 100 mg.
of streptomycin every day and follows the pa-
tient’s progress with daily audiograms. If im-
provement is noted after ten days, he continues
the treatment once or twice a week for six-
months.

He emphasizes the facts that individual sensi-
tivity as well as dosage are important. Symptoms
developed in 1 of his patients after taking only
2 gm. of streptomycin. He states that otalgia is
an early symptom and precedes the tinnitus and
acoustic impairment. Ozaki presented 7 cases,
and his audiograms are convincing. One showed
a 30-decibel hearing improvement.

As far as can be determined, no other author
has reported hearing improvement by merely
discontinuing streptomycin therapy, and many
report that further impairment may occur after

506

THE JOURNAL-LANCET

the patient has ceased taking the drug. However,
he does not differentiate between the cases treat-
ed with streptomycin, dihydrostreptomycin, or
a combination of the two.

SUMMARY AND CONCLUSIONS

A review of the literature on ototoxic drugs is
presented. Although the salicylates and quinine
may produce abnormalities of the hearing mech-
anism, including deafness, these defects have
never proved to be permanent. Of all the drugs

in current use, dihydrostreptomycin is by far the
most dangerous, for it destroys the hearing pri-
marily and its effects may begin several months
after the conclusion of therapy. Streptomycin,
on the other hand, has the same bacteriologic
spectrum as dihydrostreptomycin but is primarily
toxic to the organ of balance. Therefore, there
appears to be little reason to use dihydrostrep-
tomycin either alone or in combination with
other drugs except under the most unusual cir-
cumstances.

REFERENCES

1. Pohlman, A. G., and Kranz, F. W.: On effect of certain
drugs, notably quinine on acuity of hearing. Proc. Soc. Exper.
Biol. & Med/ 20:140, 1922.

2. Covell, W. P.: Effects of drugs on the cochlea. Arch. Oto-
laryng. 23:633, 1936.

3. Falbe-Hansen, J.: Clinical and experimental histological

studies on effects of salicylates and quinine on the ear. Acta
oto-laryng. (Supp.) 44, 1941.

4. Waltner, J. G.: Effect of salicylates on the inner ear. Ann.
Otol. Rhin. & Laryng. 64:617, 1955.

5. Barr, B., Floberg, L. E., Hanberger, C. A., and Koch, H.:
Otological aspects of streptomycin therapy. Acta oto-laryng.
(Supp.): 75:5, 1949.

6. Glorig, A., and Fowler, E. P.: Tests for labyrinth function

following streptomycin therapy. Ann. Otol. Rhin. & Laryng.
56:379, 1947.

7. Falkenfleth, G.: Impaired hearing following dihydrostrep-

tomycin therapy. Nord. med. 48:1033, 1952.

8. Liden, G.: Loss of hearing following treatment with dihydro-
streptomycin or streptomycin. Acta oto-laryng. 43:551, 1953.

9. Nilsson, J. M., and Bleck, E. E.: Neurotoxicity of strepto-
mycin and dihvdrostreptomycin. Ann. Otol. Rhin. & Larvng.
66:390, 1957. '

10. Risker, N., Christensen, E., Peterson, P. V., and Weii>-

man, H.: Ototoxicity of neomvcin. Acta oto-laryng. 46.

137, 1956.

11. Ozaki, T.: Prevention of adverse effects of streptomycin on

the ear. Arch. Otolaryng. 66:673, 1957.

In this era of antibiotics, lateral sinus thrombosis caused by chronic otitis
media must not be forgotten. Atypical cases are being encountered through-
out the country.

Haphazard antibiotic therapv of otitis media without myringotomy may
lead to a relatively asymptomatic chronic illness accompanied bv intracranial
extensions, ehieflv thrombosis of the lateral sinus.

The rules established over twenty years ago still apply to the treatment of
mastoid disease. Thev include removal of affected structures, adequate drain-
age of the infected area, and prevention of dissemination.

If symptoms of lateral sinus thrombosis exist or if, at mastoidectomy, the
jugular vein appears abnormal, the best and most conservative approach is
venal ligation before sinus manipulation in order to prevent possible dislodg-
ment of an embolus into the circulation.

Homer Kimmick, M.D., and David Myers, M.D., Temple University, Philadelphia. Arch. Oto-
laryng. 68:156, 1958.

DECEMBER 1958

507

Some Responsibilities of the Physician in
the Care of the Emergency Room Patient

JOHN T. PHELAN, M.D.

Madison, Wisconsin

The physician’s responsibility in the care of
the emergency room patient has been the
subject of numerous articles in the surgical and
medical literature. For the most part, these re-
ports are concerned principally with the care
and management of the severely injured pa-
tient.1-4 However, as the great bulk of cases seen
in the emergency room consist of soft tissue in-
juries in ambulatory patients, this paper is direct-
ed primarily to their initial treatment with em-
phasis on wound care.

In addition, I wish to discuss briefly the re-
sponsibility of the medical profession in the man-
agement of an emergency room service in the
light of the increased importance the emergency
room is assuming in most communities.

EARLY WOUND MANAGEMENT

Wound care must be distinguished from wound
suturing. The former must conform to surgical
principles, whether the wound is major or minor
in nature. Hence, every wound requires a cer-
tain sequence of events in its preparation. All
wounds are contaminated, and it is the physi-
cian’s responsibility to prevent further contami-
nation as soon as they come under his care.
Therefore, the following procedures should be
employed for every wound— large or small.

1. Be sure that all personnel assisting in the
management of the patient wear masks, caps,
and gloves.

2. Provide for adequate anesthesia.

3. Cover the wound with sterile dressing, and
clean the adjacent skin edges with mild soap and
water. This preparation should be as efficient as
if one were scrubbing his hands for an elective
surgical procedure.

4. Drape the wound with sterile skin towels.

5. Irrigate the wound with copious amounts
of normal saline solution.

6. Remove all devitalized tissue and foreign
material, and irrigate the wound again with nor-
mal saline solution.

john t. phelan is affiliated with the Department of
Surgeru at the University of Wisconsin Medical
ScJwol in Madison.

7. Secure hemostasis.

8. Remove drapes and gloves, and, with clean
gloves, cover the wound again with sterile dress-
ing and wash the skin again with soap and
water.

9. Redrape the wound, and the repair is in
order.

The aforementioned may seem to be rather
rigid principles to apply to all wounds, particu-
larly minor lacerations. Nevertheless, they are
basic surgical principles of wound care. Dabbing
various antiseptic solutions in and about a wound
serves little purpose in any wound preparation.
In addition, no amount of antibiotics ever re-
places adequate wound care.

In most instances, a minor laceration treated
in a civilian practice can be closed primarily.
Fine catgut, preferably 0000 plain, is used to
obliterate the subcutaneous dead space and,
when employed, should be kept at a minimum.
Sutures of 00000 fine silk or nylon are preferred
for skin closure. A fine, dry gauze dressing or
teflon is employed as the final dressing. In our
institution, dressings treated with ointments are
discouraged.

Occasionally, delayed closure of a minor lacer-
ation is required, principally those incurred dur-
ing a time of disaster, such as a tornado, and in
wounds simulating a wartime injury. Further-
more, bite wounds, whether human or animal in
origin, are best treated by delayed closure.5 Ex-
ceptions to this rule are bite wounds involving
the face.

Certain types of lacerations require special
technics for their closure. In this regard, Daven-
port'1 has recently emphasized this aspect of
wound care, with particular attention given to
the repair of partial skin avulsion and trap-door
and oblique types of lacerations involving the
face. When wounds of this nature are closed
in the conventional manner, scar formation de-
velops in the direction of the wound, resulting in
an elevated ridge of scar tissue. On a smooth
skin surface like the face, this ridge becomes
unduly prominent and leads to considerable dis-
figurement. To circumvent this condition, Daven-

508

THE JOURNAL-LANCET

A

Fig. la. Trap-door type of laceration and contraction
effect that results when such a wound is closed in the
usual manner, (b). Suggested method of closure with
total excision of partially avulsed segment and adjacent
skin margins. ( Reproduced with permission from Daven-
fort, G.: J.A.M.A. 166:1324-1326, 1958).

A.

Fig. 2a. Oblique type of laceration and the resulting
prominent ridge of scar tissue due to its contraction in
the direction of the wound, (b). Proposed closure with
development of perpendicular skin margins so contrac-
tion is distributed equally to each margin. ( Reproduced
with permission from Davenport, G.: J.A.M.A. 166:

1324-1326, 1958).

port suggests excising the wound edges so that
they become perpendicular, and, in this manner,
the scar formation is equally distributed to each
wound margin. His methods of repair are graphi-
cally illustrated in figures 1 and 2 and are self-
explanatory.

EMERGENCY ROOM MANAGEMENT

The emergency room service has been defined as
a medical unit which has as its primary function
the treatment and care of the acutely sick and
injured.7 In this country, most emergency room
services have been extended, and, in addition,
they serve as a place to perform minor surgery
and administer parenteral injections and as a
dressing station for the postsurgical patient.
Furthermore, the general public increasingly
tends to bypass the physician and seek advice
and care from the emergency room for conditions
they consider to be urgent. In some areas, the
emergency room is considered a health center
for the community. If this pattern of medical
care continues to persist— and present studies in-
dicate that it will8— the emergency room in many

communities will require a reappraisal to meet
this changing concept of medical care.

Suffice to say, numerous problems will have
to he solved. However, first and foremost will
be the responsibility of the medical profession
to insure adequate care and management of the
sick and injured. In many institutions, tliis will
require that the emergency room service be
staffed by full-time physicians. The type of
physician qualified for such duties is difficult
to define. However, the experiences gained dur-
ing World War II and the Korean campaign
and from communities in which disasters such as
hurricanes and tornadoes have struck indicate
the value of an experienced physician who is
primarily concerned in directing the manage-
ment of injured and acutely ill patients. The
similarity of practice under wartime and disaster
conditions is comparable to many present-day
emergency room services and is even more ob-
vious with the possibility of an atomic attack
and the problem of managing mass casualties.

The foregoing has been further elaborated on
by Howell and Buerki,9 and their comments are
worthy of repetition: “The emergency room
should he a major source of expert diagnosis and
treatment in almost any community, a vital fac-
tor in hospital-public relationship, since its pro-
fessional reputation often rides on the fate of
patients’ care in its emergency unit.”

It is apparent that the emergency room staff’d
by experienced physicians is the ultimate an-
swer. In many instances, the cost of maintaining,
as well as obtaining, such physicians will be ex-
pensive, and the question, “Can we afford it?”
will be asked. The answer to this is, “Can we
not afford it?” In the meantime, we must do the
best we can with that which we have available.
However, at the same time, the medical pro-
fession is required to give serious consideration
to the reappraisal of the purpose and function of
the emergency room service with respect to its
increased importance in most communities.

REFERENCES

1. Early care of acute soft tissue injury. Committee on Trauma,
Am.' Coll. Surg., 1956.

2. Koch, S. L.: Treatment of lacerated wounds. Surgery 38:
447, 1955.

3. C Tu.: Minor open wounds. Surg., Gynec. &
Obst. 102:369, 1956.

4. Symposium on emergency surgery of trauma. S. Clin. North
America, October 1956.

5. Gfimes, E. L., and Manges, L. C., Jr.: Treatment of hu-
man bites of the hand. Am. J. Surg. 78:793, 1949.

6. Davenport, G.: The windshield injury. J.A.M.A. 166:1324,
1958.

7. Lowden, T. S.: The casualty department: the work and the
staff. Lancet 2:955, 1956.

8. Shortliffe, E. C., Hamilton, T. S., and Noroian, E. H.:
The emergency room and the changing pattern of medical
care. New England J. Med. 258:20, 1958.

9. Howell, J. T., and Buerki, R. G.: Emergency unit in
modern hospitals. Hospitals 31:37, 1957.

DECEMBER 1958

509

Communicable Diseases

Rheumatic Fever: a Review

ROBERT B. TUDOR, M.D.
Bismarck, North Dakota

This paper is based on my experience during
the ten-year period 1949 to 1958, inclusive,
with 135 children who had acute rheumatic
fever and on a review of the literature.

Hippocrates, who is believed to have been
born in 460 B.C., wrote probably the first case
report of a disease very much like that which
we call rheumatic fever.1 The next mention of
the disease was by Aretaeus in 100 A.D. Aristotle
referred to polyarthritis in his writings, and
Galen also described arthritis. Baillou, in 1642,
was the first to use the term rheumatism in
describing acute polyarthritis as a separate dis-
ease. Sydenham made a life study of rheumatic
fever and, in 1676, distinguished acute rheuma-
tism from gout. He not only described chorea
but also described a juvenile form of poly-
arthritis. Hogarth, in the early eighteenth cen-
tury, coined the term “rheumatic fever and, in
the late eighteenth century, described the card-
iac symptoms. In 1728, Boerhaave recognized
that the disease invades “sometimes the brain,
lung, and bowels.’ Twenty years later, Storck
described pleural and pulmonary involvement in
rheumatic fever, which be corroborated by post-
mortem examinations. Pulteney, in 1761, Baillie,
in 1797, and Laennec, in 1819, first recognized
the involvement of the pericardium in rheumatic
fever. In 1786, Lettsom recorded a description
of a typical case of fatal rheumatic fever in a
child. Pitcairn, in 1788, and Jenner, in 1789,
were the first to associate rheumatic carditis
definitely with rheumatic polyarthritis. Wells
first described rheumatic nodules in 1810; how-
ever, the first comprehensive clinical description
of subcutaneous nodules was written by Barlow
and Warner in 1881. 2 In 1831, Bright recorded
instances of “roseola annulata” in association

robert h. tudor is a pediatrician at the Quain and
Ramstad Clinic, Bismarck.

with chorea and also pointed out the close re-
lationship between chorea and “affections of the
pericardium." In 1835, Bouillaud emphasized
the constant association of rheumatism and heart
disease, stressing the frequent occurrence of
endocarditis as well as pericarditis with rheu-
matism. In 1843, Watson recognized rheumatic
fever as essentially a disease of childhood. He
stated that “the younger the patient is who
suffers acute rheumatism, the more likelv will
he be to have rheumatic carditis.” In 1889,
Gheadle described the association of tonsillitis,
polyarthritis, carditis, and chorea with rheu-
matic fever. He recognized erythema margina-
tum and other rashes which occur in the disease.
The Aschoff bodv was described by Aschoff
in 1904. 2

Infection with group A hemolytic streptococci
is now recognized as the onlv established incit-

O J

ing factor in acute rheumatic fever.4-7 The possi-
bility that other infections or injuries may also
act as inciting agents in rheumatic fever has
long been considered, but there is no clearly
documented evidence that any of these can ini-
tiate the disease without the intervention of an
associated streptococcal infection. While the
streptococcus must be considered the specific
inciting agent in rheumatic fever, other factors
obviously participate in the pathogenesis of the
disease, since rheumatic fever does not develop
in all patients with recognized streptococcal in-
fections. Environmental conditions, such as
povertv and overcrowding, have not been ade-
quately assessed, and it is possible that thev mav
influence the incidence of streptococcal disease.
The roles of heredity, nutrition, and other host
factors are likewise poorly defined, and much
further work will be needed before their true
significance in the disease can be established.
Uchida8 feels that rheumatic fever is determined
primarily by an inherited susceptibility of the

510

THE JOURNAL-LANCET

host and that the eventual development of the
disease depends upon exposure to certain en-
vironmental factors. The exact method of ge-
netic transmission is as yet uncertain. Based
upon the figures from the Hospital for Sick
Children at Toronto in which 420 children from
104 families were analyzed, the chance of having
a second rheumatic child is approximately 10
per cent.

With few exceptions, bacteriologic studies
done during the onset of acute rheumatic fever
have revealed the presence of group A strepto-
cocci. Almost all patients with untreated group
A streptococcal infections in whom late compli-
cations may or may not develop continue to har-
bor the infecting organism in the throat for many
months and, in some instances, years. The per-
sistence of streptococci beyond the stage of
symptomatic infection may represent a hazard to
the individual harboring these organisms. De-
layed treatment of streptococcal infections—
treatment initiated after all symptoms and signs
of the respiratory illness have subsided— reduces
the incidence of subsequent rheumatic infection.
Such treatment eradicates the infecting organism
but does not appreciably inhibit the antistrep-
tolysin O response. Rheumatic fever can often
be prevented even if specific treatment is begun
quite late in the course of a streptococcal in-
fection. Significant increases in antistreptolysin
O titer develop in approximately 70 to 80 per
cent of patients with untreated streptococcal in-
fections. Among patients with acute rheumatic
fever, 85 per cent in 1 series showed a significant
increase in antistreptolysin O, and 90 per cent
showed a titer of 250 units or more at the time
they were hospitalized for rheumatic fever. The
fact that penicillin treatment of streptococcal
infections both inhibits antibody formation and
prevents rheumatic fever suggests that antibody
formation may have something to do with the
development of this late complication. More
recent evidence suggests the importance of the
persistence of streptococci in body tissues in the
pathogenesis of the disease. On the average,
patients with acute rheumatic fever produce anti-
bodies in larger amounts than patients with un-
complicated streptococcal infections. Stetson9
showed that the attack rate was 2.7 per cent re-
gardless of the initial antistreptolysin O titer. The
attack rate of rheumatic fever is not significantly
greater in the child than in the adult.

A beta hemolytic streptococcal infection may
be defined in terms of those clinical, epidemi-
ologic, and laboratory features which are easily
recognized by the practicing physician.10 The
clinical and epidemiologic syndromes are as

follows: (1) scarlet fever; (2) pharyngitis, with
or without tonsillitis, manifested by local redness,
edema, exudate, and elevated temperature and
associated with enlarged tender lymph nodes at
the angle of the jaw, leukocytosis, or a positive
throat culture; (3) complications of upper res-
piratory disease or syndromes which are fre-
quently due to the streptococcus, such as otitis
media, mastoiditis, and erysipelas; (4) upper
respiratory infection occurring in individuals
living in households or in close contact with
patients with obvious streptococcal disease; and
(5) symptoms at all suggestive of streptococcal
disease in known rheumatic patients or their
familial household contacts.

As with other laboratory tests, a throat cul-
ture may be misleading unless properly taken,
processed, and interpreted.11 For example, a
common error is to confuse the nonpathogenic
green, alpha streptococci with those which pro-
duce upper respiratory infections. It is, there-
fore, essential for the physician to have some
knowledge of the entire procedure, both to
insure that the culture is correctly taken and
handled and to evaluate the reports received
from the laboratory. Beta hemolytic strepto-
cocci are most easily identified on sheep blood
agar plates. An adequate culture of the throat
should be obtained by depressing the tongue
and rubbing the swab over each tonsillar area
and the posterior pharynx. Anv area exhibiting
exudate should also be touched. The swab
should be inoculated onto a blood agar plate in
one or two hours. The objectives in streaking a
blood agar plate are to avoid drying of the
specimen by delay, to insure adequate distri-
bution so that well-isolated colonies will be pres-
ent for examination, and to provide subsurface
as well as surface hemolysis for observation.
Inoculated plates are incubated overnight at
37° C. A complete laboratory report indicates
the relative number of colonies of beta hemolytic
streptococci that are present as well as the type
of hemolysis. Hemolytic streptoccal infection
during the first four years of life is characterized
by the lack of an acute onset, little or no fever,
rhinorrhea, a protracted course, and the occur-
rence of frequent suppurative complications.1213
The youngest infants may have low-grade fever,
diarrhea, or vomit for a week or less with a per-
sistent thin nasal discharge and excoriation
and crusting around the external nares. Accurate
etiologic diagnosis in these cases requires bac-
teriologic study of the nasopharyngeal flora and
the purulent discharges. After the fourth year,
the disease pattern changes so that progessivelv
more of the infections are associated with an

DECEMBER 1958

511

acute febrile onset, sore throat, exudative tonsil-
litis and pharyngitis, and, occasionally, a skin
rash. These different responses between children
of various ages to group A hemolytic streptococci
may be the result of serial reinfection, presum-
ably by strains of different serologic types. The
proportion of infections which are either mild,
atypical, or asymptomatic is not well established.
In young adults, they account for perhaps 40 per
cent of infections, and, in infants, they are
thought to occur even more frequently.

In the United States, the incidence of rheu-
matic fever varies from about 0.1 to 6 per cent.
There are roughly 1,000,000 people with rheu-
matic heart disease in the United States, and
about 300,000 of these are school children.14 The
onset of rheumatic fever usually occurs in child-
hood, especially between the ages of 6 and 10
years, with the maximum rate at age 8.

The pathogenesis of rheumatic fever may be
outlined as follows: a first phase of one to three
days' duration; an asymptomatic interval of
about eighteen days; an acute phase of rheumatic
activity; and a convalescent phase of variable
duration. 15,10 About 20 per cent of the cases
occur in children under 5 years of age, 50 per
cent in those between the ages of 5 and 8, and
25 per cent in persons over 8 years.1 By 15 years,
70 per cent of the affected children have already
acquired the disease.17 The initial symptom of
rheumatic fever is growing or joint pains in 25
per cent of patients, 1,1 516 chorea in 25 per
cent,1 15-17 polyarthritis in 25 to 50 per cent, 1,15-17
active carditis in 30 to 65 per cent,1718 and car-
ditis without apparent activity in 10 per cent.1
According to Wilson,1 85 per cent of the children
have one or more recurrences in the first eight
years. Cohn and Lingg2" found 75 per cent had
recurrences in the first thirteen years, and Bland
and Jones18,19 discovered 60 to 70 per cent had
repetitions of clinical rheumatic fever during
the first ten years. The chance of a recurrence
is 1 in 5 during the first five years, 1 in 10 during
the second five years, and 1 in 20 during the
third five years.18,19

The mean duration of the disease in patients
who die is six to fifteen years.1,17 Thirteen per
cent of the patients die before the end of one
year,1,21 10 to 12 per cent at the end of five
years,11819 21 17 to 29 per cent at the end of ten
years,1,21 and 30 per cent within twenty years.18,19
According to Cohn and Lingg,17 31 per cent do
not survive childhood, and 34 per cent do not
survive adolescence. After 15 years of age, 4
out of 5 children survive.1 The prognosis is
worse when patients show signs of systemic
saturation.21 Pronounced severity of the initial

attack of rheumatic fever, a greatly enlarged
heart, and congestive failure early in the disease
are serious prognostic features. Bland and Jones
found that by the end of twenty years, signs of
rheumatic heart disease had disappeared in 16
per cent of those who showed rheumatic heart
disease in their initial illness and had regressed
in an additional 15 per cent, a total of 31 per
cent with improved cardiac status. Of those
patients without detectable rheumatic heart dis-
ease in their initial illness, the condition de-
veloped during this period in 44 per cent, more
often in the first ten years. Physical activity is
restricted little or not at all in 80 per cent of
those who survived twenty years from the on-
set of rheumatic fever. From the data of Bland
and Jones,18,19 it appears that the 20-year out-
come may be considered satisfactory in approxi-
mately 56 per cent of 1,000 cases of rheumatic
fever, while earlv death or crippling heart dis-
ease was observed in 44 per cent.

Chronic rheumatic heart disease has declined
as a cause of death from 13.5 per 100,009 in-
dustrial policyholders of the Metropolitan Life
Insurance Company in 1950 to 11.6 per 100,000
in 1957. 22,23 In the same period, deaths from all
causes have risen from 638.7 per 100,000 to 657.1
per 100,000. The reduction in mortality reflects
both a lessened incidence of the disease and a
distinct improvement in survival. The survivor-
ship record of the children in a long-term follow-
up of nearly 3,000 young Metropolitan industrial
policyholders who had their acute attack during
the years 1936 to 1938 is remarkably good. The
survivorship rate after ninteen years was about
90 per cent for the children without heart in-
volvement at first observation, except for boys
10 to 20 years of age who received nursing care.
For them, the rate was 84 per cent. Among
children with heart involvement at first observa-
tion, the survivorship rate exceeded 75 per cent
for the girls under age 10 and exceeded 60 per
cent for the older girls and for all of the boys.
The record of mortality and survivorship was
generally better for the girls than for the bovs
and for the younger rather than for the older
children. Most of the deaths in this follow-up
experience were reported as due to rheumatic
heart disease. The most notable feature of the
study is the marked reduction in mortality from
subacute bacterial endocarditis, a complication
of rheumatic fever which two decades ago was
almost invariably fatal.

DIAGNOSTIC CRITERIA

The diagnostic features of the disease have been
divided by Jones into major and minor categories

512

THE JOURNAL-LANCET

dependent upon their relative occurrence in
rheumatic fever and in other disease syndromes
from which this illness must he differentiated.10
These major and minor categories have no sig-
nificance beyond their diagnostic import. The
presence of two major criteria or one major and
one minor criteria indicates a high probability of
rheumatic fever. One combination, however,
polyarthritis, fever, and elevated sedimentation
rate, is the weakest of all combinations of major
and minor criteria. Major diagnostic criteria are
carditis, as manifested by murmurs, increasing
cardiac enlargement, pericarditis or congestive
failure, polyarthritis, chorea, subcutaneous nod-
ules, and erythema marginatum. Minor diag-
nostic criteria are fever, arthralgia, prolonged
PR interval in the electrocardiogram, increased
erythrocyte sedimentation rate, presence of C-
reactive protein or leukocytosis, evidence of
preceding beta hemolytic streptococcal infection,
and previous history of rheumatic fever or the
presence of inactive rheumatic heart disease.

It is of considerable importance to distinguish
between growing pains, the joint and muscle
pains of the quiescent rheumatic patient, and
those associated with rheumatic activity.-4 When
such complaints are continuous and uninfluenced
by the application of heat or massage, other
clinical and laboratory criteria of rheumatic ac-
tivity are usually discovered on careful examina-
tion. It is hazardous to make a diagnosis of
rheumatic disease in children on the basis of
polyarthritis alone. When polyarthritis occurs
as a single manifestation following a beta hemo-
lytic streptococcal infection, the diagnosis of
rheumatic fever is not always substantiated. All
children with definite rheumatic polyarthritis not
only present clinical and laboratory evidence of
rheumatic disease but few escape obvious car-
diac damage. About 25 per cent of the patients
have polyarthritis initially, while about 40 to
66 per cent will have polyarthritis at some
time.15-16’18-19

Skin manifestations occur in 8 to 12 per
cent of children with rheumatic fever.15’16,18’19
They are usually associated with other signs of
rheumatic fever. Erythema annulare, also known
as erythema marginatum, is an evanescent macu-
lar lesion which resembles ringworm. It has a
pale, pink border or ring with central clearing.
It may occur any place on the extremities or
body. It may appear before any other rheu-
matic manifestations have been recognized, or
it may occur in well-advanced rheumatic dis-
ease. It may also appear as an isolated disease.
Erythema nodosum has been associated with
tuberculosis, streptococcal infections, rheumatic

fever, and coccidioidomycosis, and its presence
should focus attention on these diagnostic pos-
sibilities. The most satisfactory interpretation
seems to be that erythema nodosum can oc-
cur in any infectious disease, the cutaneous
manifestations being based on hypersensitivity.
Though erythema annulare is the most typical
of the skin manifestations, erythema multiforme,
purpura, petechiae, and urticaria may occur.
Subcutaneous nodules occur in 10 to 20 per cent
of patients with rheumatic fever.15’16'18’19 They
are usually associated with severe heart disease,
and they may occur during the stage of healing.
Some children who have numerous and univer-
sally distributed crops of nodules recover from
an acute rheumatic episode and seem to present
a good outlook for the future. In other patients,
subcutaneous nodules develop in the terminal
stage of the disease. These small structures are
about the size of a pea and appear under the
skin, on the tendon sheaths at the elbows, knees,
ankles, and fingers, and often over the occiput
where they may be bigger and painful.

Nosebleeds occur in almost a third of children
with rheumatic fever.18’19 Their repeated oc-
currence during obscure ill health should arouse
suspicion. Severe nasal bleeding is not seen as
frequently as formerly.

Chorea ( rheumatic encephalitis ) has been re-
ported to occur in 50 per cent of all rheumatic
fever patients during some phase of their ill-
ness.15161819 In a twenty-year follow-up study
made by Bland and Jones,1819 the mortality due
to rheumatic heart disease twenty years after
onset of rheumatic fever was 59 per cent among
those with an initial rheumatic manifestation
other than chorea, as compared with 12 per cent
in those whose initial rheumatic manifestation
was chorea alone. Data obtained by Taranta
and Stollerman-5 and Harris and associates26 sug-
gest that the symptom complex of chorea can
exist apart from the disease of rheumatic fever.
Rheumatic chorea would be suggested by ab-
normal levels of one or preferably two acute
phase tests and at least one elevated strepto-
coccal antibody titer. Nonrheumatic chorea
would be suggested by acute phase tests and
streptococcal antibody titers within normal limits.
Girls suffer from chorea more than boys. The
earliest complaints are those of nervousness and
clumsiness. Then uncontrolled involuntary move-
ments develop, and the patient has difficulty in
walking. The purposeless motions may interfere
with all normal activity and may involve drop-
ping objects, facial grimacing, excessive flourish-
ing of the hands, emotional instability, and men-
tal dullness. In hemichorea, the manifestations

DECEMBER 1958

513

are limited to the extremities on one side of the
body. With so-called “limp” chorea, the pa-
tient walks as if he had hemiparesis. Apparent
residual brain damage may occur after repeated
attacks of chorea.

Children who present signs of bronchitis dur-
ing the course of rheumatic activity do not do
well as a rule. These cases are usually associated
with severe carditis. Rheumatic pleurisy is more
common and is usually indefinite, evanescent,
and easily controlled. Rheumatic pneumonia
usually carries a poor prognosis. In its severe
form, it becomes manifest as a fulminating
pneumonitis and is almost always fatal. It may
also occur as a mild transitory pneumonia. Radio-
graphic evidence of rheumatic pneumonia is
usually perihilar and resembles that of congestive
heart failure.”7 -8

Rheumatic abdominal pain may be due to
enteritis, pericarditis, perihepatitis, or perisple-
nitis. 1 have not had difficulty in distinguishing
this rheumatic pain from that of acute appendi-
citis. but an oral or intravenous dose of salicylate
is said to be of help in establishing the diagnosis.
I believe that abdominal manifestations of rheu-
matic activity are not common. Enlargement of
the liver without signs of right heart failure is
significant of acute carditis and severe rheumatic
fever. Nephritis occurs somewhat more frequent-
ly in patients with rheumatic fever and rheu-
matic heart disease than is usually suspected,
and the heart may become involved despite pre-
dominant involvement of the kidneys in certain
cases of nephritis. In a recent clinical and post-
mortem series, 4.2 per cent of the nephritic pa-
tients had acute or chronic rheumatic involve-
ment of the heart, while, in the rheumatic series,
5 per cent had acute or chronic glomerulone-
phritis.29 Taran24 describes a specific nephritic
syndrome— renal epistaxis— which occurs in as-
sociation with acute carditis. This syndrome is
manifested by profuse bleeding from the kidney
and severe secondary anemia.

The most common and serious manifestation
of rheumatic fever is carditis. This condition is
always found in fatal cases and its presence,
associated with other evidence of rheumatic
fever, can be assured with the appearance of
significant murmurs, progressive cardiac enlarge-
ment, pericarditis, or congestive failure in per-
sons under the age of 20. 1 81 9 When there is no
evidence of congenital heart disease or renal dis-
ease, the development of signs of cardiac decom-
pensation in a child must be considered of rheu-
matic origin until proved otherwise. It is esti-
mated that about 10 per cent of children with
rheumatic fever have a cardiac murmur without

other evidence of the disease. The physical signs
of early involvement of the heart are essentially
those of mitral and aortic valve injury, usually
associated with cardiac enlargement. The un-
stable character of the cardiac rate, the ever-
changing heart sounds and murmurs, and the dis-
turbance in relationship of systole to diastole
are the primary criteria for rheumatic carditis.
The cardiac rhythm in acute carditis simulates
embrvocardia.24 Taran24 found that all patients
who died while they had active rheumatic fever
or as a result of active rheumatic heart disease
in whom histologic examination of the heart
was made showed signs of pericardial involve-
ment. A pericardial friction sound is sharply
localized, rough, and superficial. A blowing
systolic murmur maximal at the apex of grade

3 or greater intensity is the most common aus-
cultatory finding of mitral insufficiency. It is
usually well transmitted laterally to the left lung
base. Lesser degree of mitral regurgitation may
be temporarily present, especially in children, as
a result of other mechanisms than actual valve
deformity. Transient murmurs of this degree
may accompany cardiac dilation during diseases
other than rheumatic fever, especially when
severe anemia is present.

“Functional murmurs or “innocent murmurs,”
which are common in children, may be due to
valvular pathology with minimal clinical disease.
These murmurs are heard more often over the
pulmonic area but may be heard at the apex,
within the apex, or over the entire precordium.
A clinical and graphic study was made recently
in 500 unselected children between the ages of

4 and 17.30 From the clinical point of view, a
medium or loud systolic murmur was heard in
23.3 per cent of the cases. Even though the
majority of the systolic murmurs were pulmonic,
a fair number were heard at the apex and over
the aortic area. This study seems to indicate a
mitral origin in over one-half and a pulmonic
or aortic origin in the rest. The authors present
2 alternative hypotheses:

1. That the murmurs are caused by a discrete
rheumatic process which has different char-
acteristics from the more severe forms and
which, in the majority of cases, is not fol-
lowed by important valvular lesions.

2. That the murmurs are due to nonrheumatic,
possibly allergic, valvulitis, with no tend-
ency to increase in severity.

In either case, they consider it impossible to
separate these murmurs from those of valvular
lesions which have greater clinical significance.
Among 6,413 cases referred to Dr. Paul White
for cardiovascular opinion, rheumatic heart dis-

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THE JOURNAL-LANCET

ease was found in 27 per cent of all patients with
loud apical or aortic systolic murmurs without
diastolic murmurs and in only 3 per cent of those
with lesser murmurs and in none of those with-
out murmurs.31 Those with the loudest murmurs
lived shorter lives than those with lesser mur-
murs. There was no evidence that the prognosis
per se was more unfavorable for patients with
aortic systolic murmurs without diastolic mur-
murs than for those with the corresponding
apical systolic murmurs. Moderately to much
enlarged hearts contributed to an early death
in all patients. The aortic valve is often involved
in rheumatic heart disease. As a matter of fact,
aortic regurgitation occurs more frequently than
is generally appreciated. Clinically, the murmur
is described as a faint blowing, diminuendo,
diastolic murmur, audible over the aorta and of
maximum intensity in the third left interspace
along the sternal border. It is transmitted in the

O

direction of the regurgitant stream, sometimes as
far as the apex. This murmur, in contrast to the
diastolic murmur of mitral stenosis, begins im-
mediately after the second sound. Auscultation
with the Bowles diaphragm chest piece facilitates
perception of this low intensity murmur.

The presystolic Austin Flint murmur may be
heard in any form of well-developed aortic in-
sufficiency. It is indistinguishable in quality and
timing from the presystolic murmur of mitral
stenosis. A loud and snapping first apical sound
is a fairly common sign of mitral stenosis. It
may even be the first suggestion of fibrosis and
early stenosis. It is more significant when as-
sociated with an accentuated second pulmonic
sound. The rapid flow of blood from auricles to
ventricles during the early diastolic period is
thought to be the primary factor responsible for
both the third heart sound and the early diastolic
murmur. The appearance of a third heart sound
in a patient with active rheumatic carditis is
important because it may presage the appear-
ance of an apical diastolic murmur.

A soft, short, mitral diastolic murmur, the
Carey Coombs murmur, may occur in active
rheumatic carditis when the mitral valve is
scarcely altered. It is thought to be due to tur-
bulence set up by inflammatory thickening of the
mitral cusps. This murmur occurs early in the
course of rheumatic carditis and may disappear
as activity subsides. After the mitral valve has
become scarred and stenosed, an apical presy-
stolic murmur may be heard. The presystolic
murmur occurs in late diastole, usually sharply
limited to the apex. It is described as crescendo,
terminating with a loud snapping first sound.
In the patient with longstanding rheumatic dis-

ease and chronic congestive heart failure, the
tricuspid valve may become involved either by
actual rheumatic process or by an irreversible
dilation of the tricuspid ring. Most patients show
a leukocytosis during the first two weeks of rheu-
matic carditis. After the white blood count has
returned to normal, clinical evidence of active
rheumatic disease may still exist. An increase
in the pulse rate out of proportion to the tem-
perature is evidence of continued rheumatic
activity. On the other hand, a normal pulse rate
is no assurance that the rheumatic activity is
quiescent. An anemia may be found at the on-
set of rheumatic fever. However, this is not a
test that can be relied on to help with diagnostic
problems, as evidence of rheumatic activity may
coexist with a normal hemoglobin. A sharp re-
duction in vital capacity may be one of the
earliest signs of left ventricular failure. It has
been suggested that a low vital capacity in a
rheumatic patient should be considered a good
index of rheumatic activity in the heart muscle.
A normal vital capacity may occur with active
rheumatic fever, so it fails to be of specific diag-
nostic help.

Radiographic evidence of cardiac enlargement
occurs primarily during active rheumatic disease.
The increase in heart size is generalized in char-
acter, though left ventricular and left auricular
enlargement may occur early. Posterior enlarge-
ment of the left auricle is demonstrated best in
the oblique view after a barium swallow. Ad-
vanced valvular disease may occur with no car-
diac enlargement visible on the radiograph. The
QT interval, which measures the duration of
electrical systole, is prolonged in hypoglycemia
and hypopotassemia and shortened in hypercal-
cemia. Quinidine prolongs the QT interval while
digitalis shortens it. Carditis causes a prolonga-
tion, while pericarditis may cause a pronounced
shortening of the QT interval.32’33 Measurement
of the QT interval in patients with rheumatic
fever is an additional laboratory aid which may
help in determining the presence of active cardi-
tis. The prolongation of the QT value in poly-
arthritis and in chorea in the absence of other
clinical findings should suggest further observa-
tion for the possible presence of a mild carditis.
In evaluating patients whose QT interval is
above normal and in whom the presence of ac-
tive carditis is otherwise questioned, considera-
tion must be given to the fact that the QT in-
terval has exceeded the upper limits of normal
in some normal children.33 Serial electrocardio-
grams may show changing values for the PR in-
tervals as well as prolongations of the PR inter-
val during active rheumatic fever. Electrocar-

DECEMBER 1958

515

diographic evidence of rheumatic fever is not
usually specific enough to aid in early diagnosis.

Group A streptococci are made up of a num-
ber of recognized cellular components and give
rise to a variety of extracellular products. This
list includes many substances that are both anti-
genic and biologically active. The determination
of antistreptolysin O is in many respects the best
procedure available for routine use.34,35 Not only
is the percentage of patients showing an antibody
response to this substance as high as that to any
other single antigen, but the method of Todd is
well standardized in terms of the units of anti-
body measured. A detectable rise in the antibody
appears in the second week after the streptococ-
cal infection, and the peak is usually reached
between the third and fifth weeks. Symptoms
of rheumatic fever usually become manifest be-
fore the antibody response reaches its maximum.
Following a streptococcal infection, the changes
in gamma globulin level are similar to the
changes in specific antibody titers. A number
of changes occur in the blood during the acute
phase of infections which, though nonspecific,
may prove of help in the early diagnosis and
measurement of activity in rheumatic fever. The
changes that bring about an increased erythro-
cvte sedimentation rate may serve as an index
of the presence of active disease.

In 1930, Tillet and Francis36 demonstrated
that acute-phase serum from patients with pneu-
monia and other infectious diseases forms a pre-
cipitate in the presence of dilute solutions of the
somatic C-polysaccharide of the pneumococcus.
The C-reactiye protein is not normally present
in the blood but appears during the acute phase
of infectious disease and disappears with clin-
ical recovery. While sera from patients with
acute rheumatic fever always contain C-reactive
protein, sera from many patients with diseases
which must be differentiated from rheumatic
fever, other collagen diseases, various infections,
and malignant diseases may contain C-reactive
protein in relatively large quantities. Regardless
of its lack of specificity, detection of C-reactive
protein in the serum may be a useful index of
disease activity in rheumatic fever. Its absence
from the serum points the diagnosis in other
directions, and its detection in high concentra-
tion renders a tentative diagnosis of rheumatic
fever more acceptable. Elevations in serum mu-
coproteins, combinations of amino sugars ( hexos-
amines) with globulin, are found in children
with bacterial and virus infections, collagen dis-
eases, malignancies, and rheumatic fever. Ele-
vated serum levels of these substances were ob-
served at some time during the illness of all but

3 of 40 patients with acute rheumatic fever but
in none of 40 patients with convalescent rheu-
matic fever and in only 3 of 40 patients with
inactive rheumatic fever.37 Extensive investiga-
tions have shown that the serum level of non-
specific hyaluronidase inhibitor is elevated in
many diseases and that, like the sedimentation
rate, C-reactive protein, and mucoproteins, hval-
uronidase inhibitor levels return rapidly to nor-
mal when the clinical activity of infection, ne-
phritis, and rheumatic fever subsides.

Because of the variety of clinical signs and
symptoms of rheumatic fever, the diagnosis may
be difficult initially and may involve a great
number of other diseases with similar signs and
symptoms. Tics or habit spasms are common
and are always repeated with the same pattern.
The twitching of the lip or arm or the shrug-
ging of a shoulder is always the same, with no
muscle spasm of other parts of the body. Hemi-
chorea may be confused with a brain tumor or
poliomyelitis unless the reflexes are cheeked care-
fully and a complete examination performed,
which should include a brain wave in borderline
patients. Children with aseptic meningitis may
have confusing signs, which are resolved by a
lumbar puncture. The rapid pulse and elevated
temperature of hyperthyroidism are easily con-
fused with rheumatic carditis, especially if a
heart murmur exists. If the expected improve-
ment does not occur after corticosteroids have
been administered for a few days, diagnosis
should be questioned. A protein-bound iodine
determination or l131 uptake determination will
establish the diagnosis.

The limp and acute onset of acute hip syno-
vitis may superficially resemble rheumatic polv-
arthritis. This entity occurs almost solely in chil-
dren under 5 years of age and is not accompa-
nied by swelling of the joint, high fever, or
carditis. A radiograph occasionally shows edema
about the hip. Cellulitis or osteomyelitis become
manifest by high fever, bacteremia, high white
blood count, and intense bone pain or soft tissue
induration involving areas far removed from the
joint. They are not usually associated with evi-
dences of carditis. Acute vascular (anaphylac-
toid) purpura may show all the signs of rheu-
matic fever. The eruptions and other manifesta-
tions subside quickly after corticosteroid therapy.
I have never seen this type of purpura with acute
polyarthritis, though the purpura may involve
the joint areas, and the children do not seem
acutely ill unless, of course, abdominal purpura
occurs. Nonspecific leg aches and “growing
pains” are so common that the diagnosis is usual-
ly evident after the history is taken. Since osteo-

516

THE JOURNAL-LANCET

chondritis involves such specific sites as the
patella, the tibial tubercle, or the tarsal scaphoid,
this condition should rarely be confused with
rheumatic fever.

Severe anemias may be associated with heart
murmur and malaise and low-grade fever. In
sickle cell anemia, abdominal pain may be pres-
ent, joint pains and fever may occur, and cardiac
enlargement and apical systolic murmurs may be
found. Any bacterial infection may be confused
with rheumatic fever unless it is detected by a
careful physical examination, which should be
supplemented by laboratory studies, including
spinal tap and radiographs of skull, sinuses,
chest, and urinary tract. Sinusitis, unresolved
pneumonias, and congenital urinary pathology
are common, so that a search for them is almost
mandatory when fever is prolonged. Visceral
rheumatic fever probably occurs more often than
is appreciated, and some of the bizarre cases of
encephalitis, hepatitis, enteritis, and hilar pneu-
monia may be manifestations of this disease.
The onset of Hodgkin’s disease and leukemia is
marked by bone pain, joint pain, or spinal pain.
The differentiation of congenital heart disease
from rheumatic carditis may occasionally require
extensive studies, including heart catheterization,
and these conditions may occur simultaneously.
The correct diagnosis can usually be made by
the position and quality of the murmurs or a
continuous murmur, the absence of femoral pul-
sation, the presence of hypertension and cyano-
sis, the typical cardiac configuration, or evidence
of right axis deviation on the electrocardiogram.
Cassels38 suggests that dye dilution curves should
be used in differential diagnosis. Intravenous
injection of Evans blue dye in conjunction with
a recording oximeter is said to result in abnor-
mal curves in the presence of shunting lesions
associated with congenital heart disease. When
typical acute rheumatic fever occurs, diagnosis
is not a problem. Usually, suspicious borderline
or atypical rheumatic fever proves to be some
other disease. In equivocal situations, time and
trials with aspirin and corticosteroids may be
necessarv to decide whether rheumatic fever
exists. Endocardial fibroelastosis can mimic
almost every other kind of heart disease.39 A
myxoma in the left atrium can imitate mitral
stenosis.39

PREVENTION

The first attack of rheumatic fever may be pre-
vented by early treatment of the streptococcal
pharyngitis or tonsillitis with therapeutic dos-
ages of penicillin for at least seven to ten days.10
Results obtained with chlortetracycline and oxy-

tetraeyeline are less satisfactory than those with
penicillin, but the tetracyclines may be used in
individuals who are sensitive to penicillin. Sul-
fonamides are ineffective (table 1). It has been
demonstrated that the continuous administration
of sulfonamides, penicillin, or broad-spectrum
antibiotics is effective in preventing rheumatic
recurrences (table 2). The broad-spectrum anti-
biotics are less effective in continuous prophy-
laxis than penicillin and the sulfonamides. When
superimposed streptococcal infection occurs in
a rheumatic patient, penicillin should always
be used in full therapeutic dosage (table 1).
The sulfonamides are unable to eradicate strep-
tococci from the upper respiratory tract. The
tetracyclines have been used instead of penicil-
lin in the treatment of streptococcal infection in
penicillin-sensitive patients, but their ability to
eradicate streptococci is much lower. In case of
excessive exposure, as occurs in hospitals or
institutions, penicillin should be prescribed in
double the dosage recommended for continuous
prophylaxis. Prophylaxis must be continued at
least to the age of 15 or for five years after the
end of the last recognizable attack, whichever
is longer. In some patients, continuous lifetime
prophylaxis should be recommended.

TABLE 1

TREATMENT OF STREPTOCOCCAL INFECTION10

Mode of
administration

Penicillin

T etractj clines

Oral

Benzylpenicillin
( penicillin G )

250,000 units
three times a
day for 10 days

0.5 gm. four
times a day
for 10 days

Oral

Phenoxymethyl-
penicillin
( penicillin V )

Dosage approxi-
mately half that
for benzylpeni-
cillin

Intramuscular

Penicillin in oil
with aluminum
monostearate

300.000 to

600.000 units
on the 1st, 4th,
and 7th day

Intramuscular

Benzathine

penicillin

1,200,000 units
in 1 injection

TABLE 2

CONTINUOUS PROPHYLAXIS10

Mode of

administration Penicillin Sulfadiazine

Qral Renzylpenicillin 200,000 units Children:

(penicillin G) twice a day 0.5 gm. per day

Oral Phenoxymethvl- 100,000 units Adolescents

penicillin twice a day and adults:

(penicillin V) 10 gm. per day

Intramuscular Benzathine 1,200,000 units

penicillin once a month or

600,000 units
twice a month

DECEMBER 1958

517

TREATMENT

Treatment of acute rheumatic fever is based on
bed rest and the use of corticosteroids, aspirin,
penicillin, and digitalis. Bed rest is, of course,
mandatory during the acute attack. Bed rest can
vary from absolute for the severely ill child to
modified for the patient with few or no cardiac
symptoms. As soon as the temperature, pulse,
and polyarthritis have subsided, most children
are restrained with difficulty. As long as they are
restricted to the bed at this time, I can’t see that
the heart is compromised by physical activity in
bed. When a downward trend in the sedimenta-
tion rate has been established and the C-reactive
protein has disappeared from the blood, mod-
erate activity can be started. Most of my patients
are in the hospital from ten days to two weeks
with the acute illness and then are in bed at
home two weeks before they are allowed any
activity out of bed. Progression of heart disease
is probably due to either smoldering rheumatic
activity or recurrences. It is generally advised
not to limit the physical activity of a child who
recovers from his initial attack with no evidence
of valvular heart damage. Children with rheu-
matic valvular disease should be allowed to ex-
ercise without restriction, though they should
probably stop short of actual fatigue. A state of
relative adrenal insufficiency in patients with
rheumatic fever provides rationale for the use
of hormone therapy.40

A number of reports concerned with the use
of steroids in rheumatic fever have expressed
pessimism with regard to the prevention of per-
manent cardiac damage. It is hard to establish
a routine for the administration of corticoster-
oids, but a rough rule would be to give 1 mg.
of ACTH per pound daily or 1 mg. of predniso-
lone per kilogram daily. I give about 10 mg. of
prednisolone every six hours until the acute signs
of disease begin to subside and then reduce the
dose by half daily until all signs are quiescent.
Prednisolone, the hydrocortisone synthetic ana-
logue, is relatively inert as far as salt-retaining
properties are concerned, though it retains its
anti-inflammatory activity. I have not limited
salt in the diet unless congestive failure was im-
minent nor have I given potassium salts routinely.
Though some feel that aspirin should be given
routinely early in the disease, I’m impressed with
the fact that early, adequate doses of cortico-
steroids prevent cardiac damage. All of my pa-
tients with rheumatic fever, regardless of its
severity, receive a course of corticosteroid thera-
py. If congestive failure appears, the child should
be treated with digitalis and oxygen. Sodium
should be restricted, and physiologic principles

of cardiac care should be adhered to strictly.
At the beginning of therapy, all streptococci
should be eradicated from the throat by one of
the schedules shown in table 1 and the child then
started on continuous penicillin prophylaxis.

During the years 1949 to 1958, 135 children
with rheumatic fever, age 14 and under, were
seen at the Quain and Ramstad Clinic.

The initial symptoms of rheumatic fever were:

Arthritis
Active carditis
Chorea
Skin

Pneumonia

No. of patients
68
37
23
4
3

Per cent
50
27
17
2.9
2.2

No deaths occurred in patients whose pre-
senting symptom was arthritis or chorea. Among
the group with myocarditis and pneumonia as
the first symptom, 2 boys and 2 girls died.

No. of patients Per cent
Deaths 4 2.9

Among the whole group, the following other
manifestations occurred :

No . of patients Percent

Pneumonia 9 6.6

Skin 11 8

Rheumatic nodule 1

Hepatitis 2

Appendicitis 1

Chorea 28 13.3

To illustrate the fact that the early symptoms
of acute rheumatic fever may be exceedingly
variable, 2 case reports are presented.

CASE REPORTS

Case 1. P.C., a white female, who was horn Novem-
ber 14, 1947. Her first clinic admission was on April 10,
1953. One week prior to admission, a blotchy rash had
developed on her legs. Examination disclosed a well-
nourished child who did not appear acutelv ill. Her
legs were covered witli peteehiae and ecchvmoses. There
was no general glandular adenopathy. The eves, ears,
nose, and throat were normal. There was no heart mur-
mur. The liver, spleen, and kidneys were not palpable.
The rectal temperature was 99, weight was 37 lb., and
heart rate was 120. The white blood count was 11.000
with a differential of 75 per cent polymorphonuclear
neutrophil leukocytes, 20 per cent lymphocytes, and 5
per cent eosinophils. The hemoglobin was 12 gm. The
platelet count was 120,000. The peripheral blood smear
showed no dvscrasia. Bone marrow taken from the iliac
crest was stringy, and no dvscrasia could be demon-
strated. A heart roentgenogram showed a prominent pul-
monary outflow' tract and normal lungs. A diagnosis of
acute vascular ( nonthrombopenic ) purpura was made,
and she w'as treated successfully with cortisone. Her sec-
ond clinic admission was on November 13, 1957. She
had become ill one w'eek previously with cough, mal-
aise, abdominal pain, and fever. The morning of ad-
mission. she had begun gasping for breath and when
seen was acutely ill. She was complaining of abdominal
pain and had a continual cough. The skin was dry. and

518

THE JOURNAL-LANCET

no skin lesions were seen. Lymph glands were not pal-
pable. The neck and spine were not stiff or painful. The
throat was inflamed, and a purulent postnasal discharge
could be seen, which culture disclosed was due to a
mixture of alpha streptococci and Staphylococcus albus.
The eyes and ears were normal. The apex beat was heard
at the axillary line in the fourth left interspace. The
heart showed a 1 to 1 rhythm. No heart murmurs were
heard. The lungs were clear. The abdomen was soft.
The liver, spleen, and kidneys were not palpable. The
extremities were normal. The nails showed suggestive
clubbing. The genitalia were normal. The rectal tem-
perature was 100, weight was 56 lb., and pulse rate
was 160. The white blood count was 26,000 with a dif-
ferential of 82 per cent polymorphonuclear neutrophil
leukocytes and 18 per cent lymphocytes. The hemo-
globin was 11 gm. The urine contained 1 plus of white
blood cells and was otherwise normal. The admitting
diagnoses were bacteremia, pneumonitis, rheumatic fever,
and congenital heart disease. She was treated with
oxygen, digitalis, penicillin, chloramphenicol, and intra-
venous hydrocortisone. Twelve hours after admission, she
seemed improved, but the nails became cyanotic and a
grade III apical systolic murmur became audible. An
electrocardiogram taken at this time disclosed a PR in-
terval of 0.14 seconds, a QT interval of 0.28 seconds,
and right ventricular hypertrophy. About one hour
later, she suddenly expired. Postmortem examination
showed rheumatic pneumonitis, rheumatic endocarditis,
rheumatic myocarditis, and toxic congestion of the liver,
spleen, and kidneys.

Case 2. C.B., a white male, was born May 10, 1939.
At 5 prior clinic admissions, balanitis, stomatitis, cervical
adenitis, enteritis, bronchitis, and eczema were diag-
nosed. On February 4, 1953, malaise, sore throat, and
stuffv nose developed, which seemed to subside normally
until February 10, when he complained of abdominal
pain and began to vomit. His sixth clinic admission
began February 11, 1953. Examination disclosed a well-
nourished child who complained of pain in the right
flank. His rectal temperature was 99, weight was 100 lb.,
and the pulse rate was 100. The skin was normal. There
was no general glandular enlargement. The eyes and
ears were normal. The throat was 1 plus inflamed. No
heart murmurs were heard, and the lungs were clear.
The abdomen was tender along the right flank, especially
in the right lower quadrant, and, on rectal examination,
the right side was more tender than the left. The geni-
talia and extremities were normal. The hemoglobin was
13 gm., and the white blood count was 17,900 with a
differential of 92 per cent polymorphonuclear neutrophil
leukocytes and 8 per cent lymphocytes. The urine showed
2 plus albumin and 5 white blood cells per high power
field. An appendectomy was performed. The appendix
showed polymorphonuclears scattered through the mu-
cosa, submucosa, and muscularis and pronounced lym-
phoid hyperplasia. On February 13, a rectal tempera-

ture of 104 developed and a cough. The heart and lungs
were clear. A chest roentgenogram showed a slight en-
largement of the heart and a right upper lobar pneumo-
nia. He was treated with penicillin and sulfadiazine.
His throat culture revealed a staphylococcus and a dip-
lococcus. On February 16, the temperature was normal,
and he seemed much improved. Ilis white blood count
was 13,900 with 84 per cent polymorphonuclear neutro-
phil leukocytes and 16 per cent lymphocytes, and his
urine was normal. His stitches were removed on Feb-
ruary 18. On February 19, the temperature became ele-
vated. A roentgenogram on February 20 showed that
the chest was clear and that the heart was still slightly
enlarged. His temperature continued on February 21,
22, and 23. On February 23, his white blood count was
22,300, and a blood culture was sterile. On February 24,
the urine contained 1 plus bile. On February 25, he
suddenly became cyanotic and nauseated, and abdominal
distention developed. His heart tones became muffled,
the rate rapid, and his respirations shallow. A chest
roentgenogram showed a markedly enlarged heart, peri-
cardial effusion, and left pleural effusion. An electrocar-
diogram showed a PR interval of 0.24 seconds. His
blood pressure was 120/70. He was digitalized and
started on cortisone. Within twenty-four hours, he was
much improved. On February 27, his urine contained
4 plus bile, the direct serum bilirubin was 0.5-mg. per
cent, and the indirect fraction was 1.0-mg. per cent. On
March 1, 1953, a blowing, grade III apical systolic mur-
mur was heard, and the temperature was normal. On
March 4, a roentgenogram showed a slightly generally
enlarged heart, which was greatly improved since the
initial examination. On March 7, after he had received
1.5 gm. of cortisone, he became markedly depressed,
would not cooperate or stay in bed, and became hys-
terical and overactive. Choreiform motions of his hands
were noted. The cortisone was discontinued, and con-
valescence was uneventful. His chorea disappeared in
May and has not recurred. He was last seen in July 1957.
His blood, urine, sedimentation rate, and chest were en-
tirely normal. The liver could not be felt. A grade I to II
apical systolic murmur was audible. He is taking peni-
cillin continuously for prophylaxis. This patient had rheu-
matic appendicitis, pneumonitis, hepatitis, acute rheu-
matic carditis, chorea, and residual mitral insufficiency.

SUMMARY AND CONCLUSIONS

The literature on rheumatic fever has been re-
viewed. Data concerning 135 children with acute
rheumatic fever have been presented, and 2 illus-
trative case reports have been discussed.

Rheumatic fever should be ruled out when-
ever any systemic disease occurs in a child. Care-
ful study and observation may reveal evidence of
rheumatic fever in even the most obscure cases.

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DECEMBER 1958

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rheumatic fever in children. Am. J. Med. 2:368, 1947.

25. Taranta, A., and Stollerman, G. H.: Relationship of Sy-
denham’s chorea to infection with group A streptococci. Am.
J. Med. 20:170, 1956.

26. Harris, T. N., Friedman, S., and McLean, D. C.: Determi-
nation of some streptococcal antibody titers and acute phase
reactants. Pediatrics 21:13, 1958.

27. Tudor, R. B., and Kling, R. R.: Rheumatic pneumonia.

Minnesota Med. 34:437, 1951.

28. Lustok, M. J., and Kuzma, J. F.: Rheumatic fever pneumo-
nitis: clinical and pathological studv of 35 cases. Ann. Int.
Med. 44:337, 1956.

29. Hartman, S. A., and Bland, E. F.: Rheumatic fever and

glomerulonephritis; clinical and postmortem study. Am. J.
Med. 10:47, 1951.

30. Luisada, A. A., and others: Murmurs in children: a clinical
and graphic study in 500 children of school age. Ann. Int.
Med. 48:597, 1958.

31. White, P. D., Schaaf, R. S., Counihan, T. B., and Hall,

B.: Clinical significance of apical and aortic systolic heart

murmurs (without diastolic murmurs) as heard with stetho-
scope. Am. J. M. Sc. 225:469, 1953.

32. Taran, L. M., and Ordorico, D.: Electric systole ( QT inter-
val) in acute rheumatic pericarditis in children. Pediatrics 5:
947, 1950.

33. Finkel, S., and Baldwin, J. S.: QT interval during active

and inactive rheumatic fever. Pediatrics 9:410, 1952.

34. Good, R. A.: Acute-phase reactions in rheumatic fever, in

Rheumatic Fever, edited by Thomas, L. Minneapolis: Univer-
sity of Minnesota Press, 1952.

35. McCarty, M.: Antibody response to streptococcal infections,

in Streptococcal Infections, edited by McCarty, M.: New

York: Columbia University Press, 1954.

36. Tillett, W. S., and Francis, T., Jr.: Serological reactions

in pneumonia with a nonprotein somatic fraction of pneumo-
coccus. J. Exper. Med. 52:561, 1930.

37. Kelley, V. C.: Acute phase reactants; serum hexosamines in
patients with rheumatic fever and related diseases. J. Pediat.
40:413, 1952.

38. Cassels, D. E.: Diagnosis of rheumatic fever; symposium on
cardiovascular diseases. Pediat. Clin. North America 1:251,
1954.

39. Case Records of the Mass. Gen. Hosp., edited by Castle-

man, B.: New England J. Med. 256:516, 1957.

40. Kelley, V.: Role of the pituitary-adrenal system in rheu-

matic fever. Journal-Lancet 75:291, 1955.

Tuberculosis strikes people of all ages, but half of the eases reported are
among people under 45 years of age. A new case is reported in the United
States every six minutes. One-third of the nation — 55,000,000 Americans —
are believed to be infected with the germs that cause tuberculosis. Of this
number, an estimated 2,700,000 will develop tuberculosis if the present rate
of development of disease from infection continues. The largest number of
cases are found among men.

The annual cost of tuberculosis in the United States is approximately
$725,000,000, most of which is borne by the taxpayers. The cost of the disease
to the American people has increased more than $1,000,000 since 1952.

520

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Dysfunctional Uterine Bleeding
during Puberty

ALVIN F. GOLDFARB, M.D., and
MARTIN L. STONE, M.D.

New York City

Dysfunctional uterine bleeding may be de-
fined as abnormal and excessive bleeding
which arises from physiologic disturbances rather
than from pathologic processes. Hormonal dys-
function is the chief cause, but nutritional fac-
tors, vitamin deficiencies, psychogenic factors,
and systemic disease play important primary or
secondary roles. From a therapeutic viewpoint,
however, even bleeding associated with patho-
logic lesions, such as endometrial polyps, pelvic
inflammatory disease, endometriosis, and, to a
great extent, fibromyomas of the uterus, need no
longer be considered purely surgical problems,
since bleeding in such instances may be brought
temporarily under control in a manner similar
to that employed in purely dysfunctional dis-
turbances.

It has been pointed out that during the per-
iod of awakening ovarian function— puberty— or
waning ovarian function— the climacteric— the
incidence of dysfunctional bleeding tends to be
greater. This paper is concerned with the prob-
lem of excessive bleeding during puberty.

ETIOLOGY

The mechanism involved in the awakening of
pituitary-gonadal function is not completely
understood. However, it has been postulated
that either a central nervous system factor or the
growth of the primordial follicles is responsible.
Primordial follicle growth is accompanied by the
release of estrogens from the supporting granu-
losa and theca cells surrounding the follicle.
These estrogens probably stimulate the release
of gonadotrophic hormones from the pituitary.
During puberty, the majority of menstrual

alvin f. goldfarb is clinical instructor and chief of
the Gynecologic Endocrine Clinic at New York Med-
ical College — Metropolitan Medical Center, New
York City, martin l. stone is professor and di-
rector of the Department of Obstetrics and Gyne-
cology at New York Medical College.

Paper presented at the June 1957 meeting of the
Suffolk County Medical Society.

cycles are anovulatory. Usually a minimum ol
10 to 15 menstrual cycles occur before ovulation
is established because of the low irregular gon-
adotrophin titre characteristic of puberty. This
is in contrast to the excessive irregular gonado-
trophin production of the climacteric. It can
easily be seen that any type of irregular gondo-
trophic hormone production can lead to a dis-
turbance of menstrual function.

DIFFERENTIAL DIAGNOSIS

Although pituitary-gonadal dysfunction must be
considered the most probable cause of excessive
bleeding during pubescence, it should not be
forgotten that bleeding is only a symptom. The
mere presence of this symptom does not indicate
that it is due solely to hormonal imbalance.
Table 1 lists the more common causes of exces-
sive puberal bleeding.

TABLE 1

DIFFERENTIAL DIAGNOSIS

1 . Pituitary-gonadal dysfunction

2. Blood dyscrasias

3. Nutritional or metabolic disease

4. Systemic disease

5. Pelvic pathology

Blood dyscrasias are a common cause of puber-
al menometrorrhagia. Among the diseases that
may have dysfunctional uterine bleeding as a
presenting symptom are leukemia, thrombocyto-
penic purpura, various disorders of the clot-
ting mechanism, and anemias. Chronic diseases,
whether of a nutritional, metabolic, or systemic
nature, may affect the menstrual mechanism.
Since, as noted, the majority of menses at puber-
ty are anovulatory, the presence of a systemic
disease further impedes the normal maturation
of the menstrual mechanism.

Local pathologic conditions should also bo
considered among the possible causes of exces-
sive bleeding at puberty. The more common of

DECEMBEH 1958

521

these are vaginitis and trauma. Tumors occasion-
ally occur in this age group and can have un-
usual bleeding as their presenting symptom.

DIAGNOSTIC AIDS

For the diagnosis of conditions oceuring in the
reproductive years and in later life, the various
cytologic methods in common use are of great
value to the physician. However, during ado-
lescence, cytologic studies may not be so help-
ful. Table 2 lists in outline form a simple routine
that may be followed in trying to arrive at a
differential diagnosis of puberal bleeding.

TABLE 2

SUGGESTED WORK-UP

1. Complete history and physical

2. Hematologic studies

a. Complete blood count

b. Bleeding and clotting time

c. Platelet count

3. Vaginal smears for function

4. Protein blood iodine

5. Special studies

As in any problem confronting the physician,
the first steps in diagnosis consist of obtain-
ing an adequate history and performing a com-
plete physical examination. A rectal examination
should be clone routinely. Occasionally, a vaginal
examination may have to be performed. When
this is necessary, it should be done in the hospital
under anesthesia so that the greatest amount of
information may be obtained.

An integral part of the work-up is a complete
hematologic study. From this may be obtained
not only knowledge regarding the cause of the
bleeding but also a fairly concrete estimate of
the actual blood loss which has taken place. In
young Negro women, we also include a sickle-
cell study.

The use of the vaginal smear to determine the
estrogen effect gives the physician some idea of
the amounts of estrogen being produced by the
patient. The growth of the vaginal epithelium
is controlled by the estrogens produced by the
ovary. If a good estrogen effect is noted cyto-
logically, it is a reflection of good ovarian func-
tion.

The evaluation of the blood protein iodine
level is a satisfactory test for thyroid function
during puberty. We do not advocate the routine
use of radioactive iodine uptake studies during
puberty. The basal metabolic rate is subject to
many extrinsic pressures which may adversely

influence the results. When ordering a blood
protein iodine determination, it is important to
remember that the results will be influenced by
the recent use of any iodized oils systemicallv
for diagnostic purposes or the use of iodized
pharmaceutical products.

Special studies, such as a twenty-four-hour
urinalysis to determine the follicle-stimulating
hormone level or 17 ketosteroid excretion level,
diagnostic x-raV of the long bones for bone age,
or sella turcica films, are reserved for problem
cases. Other studies which may be necessary in-
clude a chest roentgenogram, glucose tolerance
curve, and erythrocyte sedimentation rate.

MANAGEMENT

The handling of these problems should be direct-
ed toward control of the immediate bleeding
episode and supportive care to place the patient
in as physiologically normal a state as possible.
We feel that although endocrine therapy may be
used in many nonendocrine cases to quickly
control the bleeding, it should not be continued
unless there is a definite endocrine basis for the
menstrual dysfunction.

The indiscriminate use of the sex steroids dur-
ing adolescence may lead to permanent impair-
ment of the pituitary-gonadal mechanism during
the reproductive years. We have arbitrarily ac-
cepted IS years as the upper limit of puberty.
After this age, our approach to the management
of excessive bleeding is different, for we are then
dealing with problems of bleeding during the
reproductive years.

Therapy of puberal bleeding is divided into
2 categories— supportive and specific. The sup-
portive measures are outlined in table 3.

TABLE 3

SUPPORTIVE MEASURES

1. Nutritional

a. Iron

b. Vitamins

c. Proteins

2. Blood replacement

3. Reassurance

The nutritional problem should be handled
with a multipronged approach. We prefer to use
multivitamins in a dose containing twice the
daily adult minimum requirements. There are
many iron preparations available for the clinician
to use. It is generally agreed that ferrous iron
is all that is needed in the pure iron deficiencv
anemia. The problem with such therapy is gastro-
intestinal intolerance. Recently, we have had

522

THE JOURNAL-LANCET

satisfactory experience with an iron chelate which
apparently has the advantages of being well
tolerated, the maximum dosage required is low,
and it is better absorbed.

Protein supplements are prescribed for these
patients daily in the form of protein hydrolysates.
In addition, they should receive a diet containing
2 gm. of protein per kilogram of body weight.
It must be kept in mind that these patients are
in a stage of growth and development, and their
protein requirements are greater than an adult's.
When whole blood is needed to overcome the
problem of acute blood loss, transfusion and
hospitalization, of course, are indicated. Intelli-
gent reassurance to both the patient and the
parent during the period of the uterine bleeding
is necessary. Because of the anxiety associated
with this type of bleeding, an intelligent and
understanding physician will allay many of the
family’s fears and doubts.

Table 4 outlines the various groups of specific
agents that are available for the treatment of
puberal bleeding.

TABLE 4

SPECIFIC MEASURES

1 . Steroid therapy

a. Estrogens

1). Estrogens and androgens
c. Estrogen — androgen — progesterone

2. Gonadotrophins

3. Aniline dyes

4. Dilation and curettage

Our method of choice consists of starting with
steroid therapy and proceeding to the remainder
of the specific agents in an orderly fashion. This
program was designed primarily as a study
method, so that intelligent observations could be
made in order to evaluate its efficacy. However,
if, in the course of work-up, a specific etiology is
found, treatment is directed toward the correc-
tion of this factor. The therapeutic measures us-
ing an hormonal approach to therapy may be
outlined as follows:

1 . Estrogens.

a. Orally: ethinyl estradiol, 1 mg. twice daily for
twenty-one days.

b. Intamuscularly: estradiol benzoate, 10,000 inter-
national units in sesame oil weekly for three
weeks.

c. Intravenously: Premarin, 20 mg. in 250 cc. of
normal saline.

Anhydroxy progesterone is given to all patients on
the fifteenth day of therapy in a dose of 25 mg. for
ten days.

2. Estrogen-androgen therapy.

Estradiol benzoate, 5,000 international units and
testosterone propionate, 50 mg. three times a week
for two weeks.

3. Estrogens-androgens-progesterone.

1 cc. of the combined product for five days.

4. Gonadotrophic hormones.

Synapoidin, 0.5 cc. three times a week for three
weeks.

5. Aniline dyes.

Toluidine blue supplied as Blutene, 100 mg. twice
daily for one week.

6. Dilation and curettage.

When using any of the preparations described,
one must be aware of the side effects of the drugs
and their contraindications. Steroid therapy
should never be used for more than 3 consecu-
tive cycles because of the possibility of damag-
ing the pituitary gonadal system. During puber-
ty, we feel that controlling the immediate epi-
sode of bleeding is the important consideration.
As it takes many cycles to arrive at the normal
ovulatory mechanism during puberty, firing of
this mechanism may not be necessary after the
bleeding is controlled.

Excess uterine bleeding during puberty is not
analogous to a similar situation during the re-
productive years or at the climacteric. Gonado-
trophic hormones are not recommended until the
other therapeutic regimes have been tried and
found wanting. Their use may be associated
with side effects, such as sensitization to the
protein, allergy, and antihormone formation.
It is always a wise step to skin test the patient
prior to using the gonadotrophic hormone.

Toluidine blue is of value in certain cases in
which the clotting mechanism is impaired due to
the presence of an increased protamine filtrable
substance in the blood. The use of toluidine blue
in most cases is a therapeutic test of the efficacy
of this compound.

In a small percentage of cases, the clinician
has to resort to dilation and curettage to control
abnormal bleeding. This procedure should be
undertaken in most cases only after all other
avenues of therapy have failed. The possible
psychic trauma from dilation and curettage in
the young patient must be borne in mind.

CONCLUSIONS

In general, the physician’s approach to the man-
agement of puberal bleeding should be based on
sound physiologic principles. The possibility
that excessive bleeding may be a manifestation
of systemic disease must always be considered.
When systemic disease exists, treatment of the
primary disorder usually results in subsidence of

DECEMBER 1958

523

the bleeding. In treating these patients, the develop by itself. Suggested regimes for the
major aim is to control the bleeding episode and management of puberal bleeding have been pre-
then allow the pituitary-gonadal mechanism to sented.

REFERENCES

1. Wilkins, L.: The Diagnosis and Treatment of Endocrine

Disorders in Childhood and Adolescence. Springfield, Illinois:
Charles C Thomas, 1950.

2. Greenbi.att, R. B.: Syndrome of large, pale ovaries and its
differentiation from adrenogenital syndrome and Cushing’s
disease. Postgrad. Med. 9:492, 1951.'

3. Greenblatt, R. B., and Barfield, W. E.: Hormonal con-

trol of functional uterine bleeding. Am. 1. Obst. 6c Gynec.
63:153, 1952.

4. Rakoff, A. E.: in Meigs Progress in Gynecology. New York:
Grune 6c Stratton, Inc., vol. 2.

5. Carrington, E. R.: Symposium on pediatrics; gynecologic

problems in preadolescent and adolescent years. M. Clin.
North America 36:1729, Nov. 1952.

By applying Tes-Tape to the cervical mucus, the increase in glucose concen-
tration that accompanies ovulation can be detected. The procedure, which the
patient can do at home, enables the rhythm method to be practiced more
easily than by calendar calculation or use of basal temperature charts.

A Tes-Tape impregnated with glucose oxidase is placed on the tip of a
cardboard tampon and inserted into the vagina for five minutes. When glu-
cose level is highest, the tape stains deep green.

After appearance of the deepest stain, coitus should be avoided for four
days by patients who do not desire pregnancy.

Joseph B. Doyle, M.D., Tufts University, Boston, and Boston College, J.A.M.A. 167:1464, 1958.

Sex can be determined by noting a special mass of chromatin in the cell
nuclei, the sex chromatin. It is regularlv found in the nuclei of normal females
but not of males.

Tests of chromosomal sex are particularly helpful in diagnosing suspected
adrenocortical hyperplasia in female infants, gonadal dysgenesis in childhood,
the testicular feminization syndrome during and after adolescence, and seminif-
erous tubule dysgenesis.

In determining the patient’s appropriate sex, test results must be consid-
ered along with such features as the anatomy of the external genitals, available
hormonal therapy, and the sex already assumed.

The oral mucosal smear is a reliable test for chromosomal sex and is simpler
than either skin biopsy or neutrophil study. The buccal mucosa is scraped,
transferred to an albuminized slide, fixed for thirty minutes in equal parts ol
95 per cent alcohol and ether, and stained with thionine, eresvl violet, or other
basic stains. Slight acid hydrolysis before staining sharpens the nuclear detail
and eliminates bacterial staining. The sex chromatin is usually planoconvex
or much flattened and adheres closely to the inner surface of the nuclear
membrane.

John C. Rathbun, M.D., Earl R. Plunkett, M.D., and Murray L. Barr, M.D., University of
Western Ontario, London. Pediat. Clin. North America, p. 375, May 1958.

524

THE JOURNAL-LANCET

WHO in an Era of Chemotherapy

WESLEY W. SPINK, M.D.

Minneapolis, Minnesota

When i was asked to speak before the
eleventh annual World Health Assembly,
I gladly accepted the invitation because of my
deep respect for the ideals and the accomplish-
ments of the World Health Organization. Any
intelligent person will agree that the major
challenge facing civilization today is the prob-
lem of how peace can be maintained throughout
the world. Regardless of national boundaries,
WHO has as its goal the elimination of sickness
and the maintenance of good health among all
people. Such aspirations promote happiness and
friendship and lead to international harmony.

I have had the privilege of acting as a con-
sultant for WHO since 1950, and I have traveled
about in several countries as a representative of
this organization. It has become quite obvious
to me that much of WHO’s success is due to the
dedicated and hard working, permanent person-
nel of this group. I have been impressed by
how much WHO has accomplished in the field
of public health with such a modest budget. It
also has been impressive to note the respect that
people at all levels of life in the different coun-
tries have for WHO.

Although WHO has just had its tenth anniver-
sary, it should be emphasized that the objectives
of this organization did not spring up overnight.
For many decades, attempts had been made
among nations to curb the spread of pestilences,
such as plague, smallpox, cholera, and typhus.
Indeed, the Pan American Sanitary Bureau was
established over half a century ago in an en-
deavor to control the spread of disease among
the nations of the Western Hemisphere. Similar
efforts had later occupied the attention of other
organizations, such as the League of Nations,
the International Red Cross, and the Rockefeller
Foundation. Because the labors of all of these
groups, including WHO, have been largely con-
cerned with the control and eradication of in-

wesley w. spink is professor of medicine at the
University of Minnesota Medical School.

Paper presented at a dinner for the delegates of
the World Health Organization and the faculty of
the University of Minnesota Medical School on
June 10, 1958, on the occasion of the eleventh an-
nual World Health Assembly.

fectious diseases, I would like to discuss briefly
the role that chemotherapy has played in this
program.

ROLE OF CHEMOTHERPY

Modern chemotherapy began in 1935 with the
sulfonamides. For the first time, effective therapy
rapidly became available for hemolytic strepto-
coccal disease, pneumococcal infections, suppur-
ative meningitis, and gonorrhea. The subsequent
introduction of the sulfone compounds proved
advantageous in the treatment of leprosy. By
1940, the attack on infectious diseases was wid-
ened through the application of Fleming’s dis-
covery of penicillin. Most gratifying to physi-
cians all over the world was the sustained effi-
ciency of penicillin against syphilis, yaws, and
gonorrhea. In 1944, the monumental achieve-
ment of Waksman was made available to medi-
cine in the form of streptomycin, which has
proved so valuable in the therapy of tubercu-
losis. Other chemicals, such as isoniazid (INH)
and para-aminosalicylic acid (PAS), reflected
further advancements in the treatment of tuber-
culosis.

It is singularly remarkable that in the decade
1935 to 1945, which immediately preceded the
founding of WHO, the greatest advancements in
the history of mankind took place in the control
and therapy of infectious diseases. And, many
of these developments occurred at a time when
civilization was gripped in the most terrifying
of all wars! Not only did the sulfonamides, sul-
fones, and antibiotics appear during this period,
but antimalarial compounds were made avail-
able, and insecticides, such as DDT, were
brought into use for the prevention of malaria
and epidemic typhus. What an appropriate time
it was to launch an international health agenev
like WHO, so that these new discoveries could
be made available to all the people in the world.

However, these advancements still left much
to be desired. Effective therapy was still lacking
for major diseases like typhoid fever and the rick-
ettsial diseases, such as epidemic typhus, murine
typhus, Rocky Mountain spotted fever, and Q
fever. Furthermore, penicillin or streptomycin
was most effective when injected parenterally

DECEMBER 1958

525

with the aid of a needle and syringe. But, in
many parts of the world, it was neither practical
nor possible to administer drugs by injection.
The really miraculous antimicrobial drug would
possess a broad spectrum of antimicrobial activ-
ity and would be one that could be administered
by mouth. Again, it is fortuitous that such a
drug made its appearance during the first year of
WHO’s existence.

Early in 1948, Aureomycin was made available
to our group at the University of Minnesota for
investigations on human brucellosis. During the
summer of that year, we treated with this new
antibiotic a group of patients seriously ill with
brucellosis in Mexico City in cooperation with
Dr. M. Ruiz Castaneda. The beneficial results
were much beyond our expectations. In similar
fashion, other groups demonstrated that Aureo-
mvcin could be effectively administered orallv
to patients having a wide variety of infectious
diseases. Additional broad-spectrum drugs soon
appeared. Terramycin had therapeutic proper-
ties similar to Aureomycin. Chloramphenicol
proved to be the most efficient agent for typhoid
fever. Modifications of both Aureomycin and
Terramycin have appeared on the market, especi-
ally in the form of the tetracycline group of
drugs. However, it is my own belief that from a
therapeutic point of view, Aureomycin yields just
as favorable results today as the more recently
introduced tetracyclines. As far as we are con-
cerned, no other drug has surpassed the thera-
peutic efficiency of Aureomycin in the treatment
of human brucellosis. For more sevei'e cases, we
do recommend a combination of streptomycin
and Aureomycin— or tetracycline. While other
antibiotics became available during the decade
1948 to 1958, their use is much more restricted
because they have a narrower range of anti-
microbial activity.

The sulfonamides, penicillin, streptomycin,
broad-spectrum antibiotics, insecticides, and anti-
malarial agents all reflect tremendous advance-
ment in the control and therapy of infectious
diseases. Never before in the history of man-
kind have the advancements been so rapid in
the management of infectious diseases as in the
last two decades. This, indeed, has been a
golden era of therapy. These advancements,
however, have created some new problems for
man— and I would say for WHO— and it is well
to take brief inventory of these problems at this
time.

PROBLEMS INDUCED BY ACHIEVEMENTS

No infectious disease has ever been treated out
of existence. I don’t know of a single strain of

gonococcus or of Treponema pallidum that has
become resistant to penicillin, and yet gonorrhea
and syphilis have not been wiped out. I have
been told that primary cases of syphilis have
actually increased recently in some areas in the
United States. Persistent vigilance along the
lines of well-established public health measures
is essential in controlling and eliminating these
diseases. Neglect of water and milk supplies in
metropolitan areas like Minneapolis or New
York could bring about frightful epidemics with-
in a short time. The pestilences of cholera,
plague, smallpox, and typhus are still serious
threats in many parts of the world. Children
still die of tetanus in Minnesota. Rabies con-
tinues as a menace to both animals and man.
These are some of the reasons why WHO should
continue to spread the sound doctrines of public
health.

Ever since Paul Erlich first applied his brilliant
concept of chemotherapy to the infectious dis-
eases over fifty years ago, considerable appre-
hension has existed concerning the possibility
that microbes woidd develop resistance to the
lethal action of the chemicals. We have learned
that this apprehension is not without some foun-
dation. As a result of contact with DDT, strains
of mosquitoes and Hies have appeared that are
resistant to this insecticide. After the large-scale
use of the sulfonamides in the treatment of gon-
orrhea, a majority of the cultures of gonococci
in some areas were found to be resistant to these
drugs. A considerable proportion of strains of
tubercle bacilli became resistant to streptomycin
following the use of this antibiotic in the treat-
ment of tuberculosis. One of the most serious
threats to human health today is the appearance
of antibiotic-resistant strains of staphylococci in
our large medical centers. The problem of ac-
quired infections in our general hospitals due to
resistant strains of staphylococci is quite serious,
and I fear that this problem will engage our
attention for a long time. However, in spite of
the appearance of antibiotic-resistant microbes as
a result of the extensive use of these drugs, it is
more remarkable that many species of micro-
organisms are still highly sensitive to the killing
effect of these agents. Penicillin has been used
extensively the world over, and yet I am not
aware of a single strain of group A hemolytic
streptococcus, pneumococcus, gonococcus, or
Treponema pallidum that has become signifi-
cantly resistant to this antibiotic.

There is no question that the modern use of
antibiotics respresents one of the greatest ad-
vancements in medical history. But. progress al-
ways stirs up new problems, and the control of

526

THE JOURNAL-LANCET

infectious diseases is no exception. I would like
to conclude by citing one or two socioeconomic
problems that have been induced in part bv this
advancement.

SOCIOECONOMIC CHALLENGE

The older clinicians used to state that broncho-
pneumonia was the old man’s friend. Instead
of lingering on with degenerative diseases that
caused intellectual and physical deterioration,
the aged person quietly slipped out of this world
after a brief attack of pneumonia. However,
now the antibiotics are prolonging life and bring-
ing with it the critical problem of caring for the
aged. On frequent occasions, many of us in hos-
pitals do not examine anyone under 70 years of
age. As life is prolonged through the control of
disease and with better nutrition, the problem of
caring for a population of advanced years will
become more and more critical.

But, the control of infectious diseases has far
greater socioeconomic connotations than pro-

longing the years of persons of advanced age.
Infant and maternal mortality have also been
reduced considerably. Let us also consider the
lives that have been saved through the control
of malaria alone or as a result oi lowering the
mortality rate of tuberculosis. If we eliminate
infectious diseases, if we provide better food and
shelter for large segments of the world, if we
abolish war, the population of the world will in-
crease at a tremendous rate, and this era may not
be too far away. When I hear about the extra-
ordinary sums of money that are being devoted
to the exploration of the stellar spaces and the
possibilities of landing on the moon, 1 wonder
if a little more effort and money should not be
devoted to the problems of space in our own
world. Better health means more people livin'*
longer and on a higher socioeconomic level. I
am certain that in the not too distant future,
WHO delegates will be contesting with problems
that we have brought about through our accomp-
lishments.

According to the Health Information Foundation, the average person
today sees his doctor about five times a year, almost twice as often as did his
counterpart thirty years ago. In the aggregate, Americans pay physicians be-
tween 800 and 850 million visits a year.

Women see physicians more often than men do, especially between the ages
of 15 through 44. During childhood, however, bovs receive more medical care
than girls.

Persons in low-income groups now see a physician almost as often as those
in high-income groups, says Health Information Foundation. Thirty years ago,
by contrast, high-income families averaged about half again as many visits to
doctors as did those with the low incomes.

527

DECEMBER 1958

Years of Progress in

o

Venereal Disease Control

E. GURNEY CLARK, M.D., Dr. P.H.
New York City

Considerable progress has been made in
venereal disease control in the continental
United States. As seen in table 1, the highest
rates for total, early latent, late and late latent
syphilis were in 1943, for primary and secondary
syphilis and gonorrhea in 1947. The decline in
reported total syphilis was continuous from 1947
to 1956 when the first rise occurred.1 Success in
control is due to constant vigilance; proper use
of penicillin; availability of adequate case find-
ing. diagnostic, and treatment facilities; availa-
bility of trained personnel; and general interest
in controlling a disease which, if untreated, could
result in blindness, heart disease, paralysis, men-
tal disorders, or death. Such vigilance and proper
surveillance must continue if the lowest attain-
able levels are to be reached.

There is an increasing number of publica-
tions which present evidence that vigilance has
been overrelaxed.--0 The decrease in vigilance
may be a result of misinterpretations of current
venereal disease statistics. Many of the reported
evaluations of these statistics are based upon
data relating to the nation’s problem as a whole
rather than the problems in specific local areas.

Despite the progressive decline in gonorrhea
and in all stages of syphilis to 1956, some im-
portant points should be considered. The rate
for total syphilis in 1956 for nonwhites is prac-
tically as high as the highest rate ever recorded
in the United States for the total population
( 1956 nonwhite — 437.9 per 100,000, 1943 total
population — 447.0 per 100,000)4 The ratio of
early latent and late and late latent syphilis to
primary and secondary syphilis has increased
materially since 1947. This means that the pro-
portion of failures in early case finding has in-
creased.

In 1932, Dr. Thomas Parian.10 who launched

e. gurney clark is professor of epidemiology, School
of Public Health and Administrative Medicine, Fac-
ulty of Medicine, Columbia University, and medical
consultant, American Social Hygiene Association.

This paper is dedicated to Professor Joseph Tomc-
sik, of the University of Basel, on the occasion of his
birthday.

America’s greatest offensive against venereal dis-
ease, stated, “Syphilis can never be controlled
while more than one-half of the cases are not
recognized for more than one year after onset.”
In 1947, in the United States, the ratio of re-
ported cases of early latent syphilis of four years’
duration or less to cases of primary and secon-
dary syphilis was about 1:1. In 1957, the ratio
was over 3:1. In regard to late and late latent
syphilis, the ratio of late and late latent cases
found to primary and secondary syphilis was
slightly over 1:1 in 1947. In 1957, the ratio was
16:1. Every case of early or late latent and late
syphilis represents a failure of previous case
finding. For the past four years, primary and
secondary syphilis has been reported at an av-
erage of 6.5 thousand cases per year. Over the
same period of time, the. number of reported
cases of early latent syphilis has averaged 21.7
thousand cases per year. Thus, for every case of
primary and secondary syphilis found during this
four-year period, at least 3 similar cases were
not found. Those discovered were found after
they had passed through the infectious period.
This means not only that more cases were missed
than were found, but also that those missed were
potential hazards to others during the primary
and secondary stages and possible infectious
relapse periods.

The Oslo study of untreated syphilis1112 in-
dicates the potential hazards of untreated pri-
mary and secondary syphilis. Approximately 25
per cent of the untreated patients had infectious
relapses within the first four years after infec-
tion. Of these, 22 per cent had more than 1
recurrence of infectious lesions. Of the untreated
syphilitics, 15.8 per cent developed benign late
lesions, 9.4 per cent of men and 5.0 per cent of
women developed neurosyphilis, 13.6 per cent
of men and 7.6 per cent of women had cardio-
vascular syphilis, and syphilis was the chief
cause of death in 10.8 per cent. Thus, failure to
discover and treat syphilis during the primary
and secondary stages adds considerable hazards
to health.

Late symptomatic syphilis is prevented by the
adequate treatment of discovered latent syphilis.

528

THE JOURNAL-LANCET

TABLE 1

CASES OF SYPHILIS ANI) GONORRHEA AND RATES PER 100,000 POPULATION
REPORTED BY STATE HEALTH DEPARTMENTS
FISCAL YEARS 1941-19571

Fiscal

year

Total
syphilis *
Cases Rate

Primary and secondary
syphilis

Cases Rate

Early latent
syphilis

Cases Rate

Late and late latent
syphilis

Cases Rate

Gonorrhea
Cases Rate

1941

485,560

368.2

68,231

51.7

109,018

82.7

202,984

s
1 lr>

193,468

146.7

1942

479,601

363.4

75,312

57.1

116,245

88.0

202,064

153.1

212,403

160.9

1943

575,563

447. Of

82,204

63.8

149,390

1 16. Of

251,958

195.7f

275,070

213.6

1944

467,641

367.8

78,418

61.7

123,019

96.7

202,780

159.5

300,585

236.4

1945

359,115

282.3

77,007

60.5

101,719

80.0

142,188

1 1 1.8

287,181

225.8

1946

363,647

271.7

94,957

70.9

107,924

80.7

125,248

93.6

368,020

275.0

1947

372,963

264.6

106,539

75. 6t

107,767

76.4

121,980

86.5

400,639

284. 2f

1948

338,141

234.7

80,528

55.9

97,745

67.8

123,972

86.1

363,014

251.9

1949

288,736

197.3

54,248

37.1

84,331

57.6

121,931

83.3

331,661

226.6

1950

229,736

154.2

32,148

21.6

64,786

43.5

112,424

75.5

303,992

204.0

1951

198,640

131.8

18,211

12.1

52,309

34.7

107,133

71.1

270,459

179.5

1952

168,734

110.8

11,991

7.9

38,365

25.2

101,920

66.9

245,633

161.5

1953

156,099

100.8

9,551

6.2

32,287

20.8

100,195

64.7

243,857

157.4

1954

137,876

87.5

7,688

4.9

24,999

15.8

93,601

59.4

239,661

152.0

1955

122,075

76.0

6,516

4.1

21,553

13.4

84,741

52.7

239,787

149.2

1956

126,219

77.1

6,757

4.1

20,014

12.3

89,851

54.8

233,333

143.9

1957

135,542

82.3

6,283

3.8

20,346

12.2

100,514

60.8

216,476

129.7

° Includes “stages of syphilis not stated’
f Highest rates

Source: Venereal Disease Fact Sheets1

but the numerous cases of late syphilis discovered
annually indicates that all latent syphilis is not
discovered in time to prevent late complications.

Today’s venereal disease problems have been
studied bv means of a questionnaire sent to all
states and territories, all cities in the United
States with populations over 100,000, and to the
District of Columbia. Replies were received from
48 states, 3 territories, 95 out of 107 cities, and
the District of Columbia. The results are pre-
sented in the fifth annual Joint Statement, To-
day’s Venereal Disease Control Problem, recently
released by the Association of State and Terri-
torial Health Officers, the American Venereal
Disease Association, and the American Social
Hygiene Association.13

Table 2 shows the number of states and cities
reporting increases in syphilis rates during the
five-year period of these annual studies.13 Al-
though there have been rises in the total num-
ber of reported cases of syphilis in all stages in
from 9 to 23 states annually since 1953, this was
not reflected in rates for the United States as a
whole until 1956 and 1957 (table 1). In 1957,
135,542 cases of syphilis were reported as com-
pared with 126,219 in 1956 and 122,075 in 1955.
The greatest change in the number of reported
cases of syphilis during 1957 is the increase of
10,663 cases of late and late latent syphilis, bring-
ing the total to 100,514 cases with a rate of 60.8
per 100,000 population. This is the highest num-
ber of late and late latent cases reported in the
United States since 1952. Twentv-six states and

25 cities showed increases in the rates of re-
ported late and late latent syphilis for 1957.

In 1957, primary and secondary syphilis de-
clined slightly in the United States as a whole
but rose in 25 cities and 20 states. Earlv latent
syphilis rose slightly in the United States as a
whole but increased in 19 cities and 21 states.

Since 1953, the number of states reporting in-
creases in gonorrhea over previous years has
varied from 15 to 27 annually. In 1957, 18 states
showed increases over 1956 in the number of re-
ported cases. Despite these local rises, the total
number, or 216,476 cases, in the United States
as a whole declined by 16,857 cases.

Health officials generally agreed that fluctua-
tions in the number of reported cases are due
to variations in the use of case-finding measures
and the extent to which state and local health
departments use well-known measures for con-
trol. An increase in case-finding activity almost
invariably results in more cases being discovered
and reported and subsequently increasing rates
of reported cases.

Twenty states, 1 territory, and 17 cities re-
ported outbreaks of venereal disease in 1957. An
outbreak is a cluster of cases which, bv epidemi-
logic investigation, have a common source and
occur within a relatively short period of time.
The number of persons involved in these out-
breaks ranged from 45 to 326. The number of
newly discovered cases of infectious syphilis in
these outbreaks ranged from 9 to 72.

Fourteen states and 19 cities reported a rise

DECEMBER 1958

529

TABLE 2

NUMBER STATES AND CITIES REPORTING INCREASE IN SYPHILIS RATES
OVER PREVIOUS YEARS13

Fiscal

year

Total Primary and secondary Early latent Late and late latent

syphilis syphilis syphilis syphilis

States Cities States Cities States Cities States Cities

1953

15+

15

8+

1954

9+

14

10+

1955

16+

19

16+

1956

23°

24

20

1957

21°

22

20+

° Rates for nation increased this year (see table 1)
fRates for nation decreased this year (see table 1)

Source: Today’s Venereal Disease Control Problems, February,

11

6+

16

21 +

17

11

5+

14

15+

19

20

11+

17

21 +

20

25

18+

21

24°

23

25

21 +

19

26°

25

1958. 13

in venereal disease among the group 11 to 19
years of age, the increases ranging from 3 to 30
per cent over the previous year.

Continued successful prevention and control of
venereal disease will depend upon the availabili-
ty of necessary control facilities, control pro-
cedures, and trained personnel.

Sixteen states, 1 territory, and 5 cities declared
that they do not have sufficient diagnostic
and treatment facilities to meet current needs.
Twenty -three states and 37 cities stated that
reporting was not sufficiently complete to pro-
vide a reliable index of actual incidence and
prevalence. A number of states and cities utilized
serologic testing in selected areas to check on
reporting. Others used routine laboratory re-
ports and premarital blood testing data as checks
on actual reports from private physicians and
clinics. Wide discrepancies were noted.

Eight states and 6 cities are not able to pro-
vide adequate contact investigation for primary
and secondary syphilis, and 21 states and 14
cities cannot provide this measure for early latent
syphilis.

Twenty-one states and 14 cities believed that
without additional federal support there would
be insufficient funds for an effective local venereal
disease control program in the coming year.

The largest problem encountered by the health
officers is a shortage of personnel to maintain
adequate control. Thirty-two states, 1 territory,
and 9 cities reported inadequate coverage of
137 areas in which 20 million persons reside.
Shortages of specific professional personnel were
reported by 28 states, 2 territories, and 12 cities.
In order to maintain surveillance and to achieve
adequate control coverage, they indicated the
additional immediate need of 35 trained physi-
cians, 53 trained nurses, 87 contact investigators,
6 laboratory technicians, 15 record analysts, and
27 health educators.

No one will deny that much progress has been
made in venereal disease control, but basic epi-
demiologic facts from various parts of the United
States reveal that the problem is still one of
considerable public health importance and may
become more important if vigilance is relaxed.

“The etiologie agents of gonorrhea and syph-
ilis are available in every state. There is no im-
munization, nor are there non-human vectors to
control through environmental sanitation. Fur-
thermore, promiscuity is common, particularly
at early ages and among certain population
groups. Constant active surveillance is therefore
essential for prevention, control, and reduction
to the lowest attainable level.”8

Copies of the annual report: Today’s Venereal Disease
Control Problem are available each year from the Ameri-
can Social Hygiene Association, 1790 Broadway, New
York City.

REFERENCES

1. Venereal disease fact sheets, U. S. Department of Health. Ed-
ucation and Welfare. Public Health Service, Venereal Dis-
ease Program, No. 9, December 1952; No. 13, December,
1957.

2. De Oreo, I.: Is syphilis still a problem? Hull. Acad. Med.

42:14, 1957.

3. Venereal disease is still a problem. Virginia Health Bull.
10:1, 1957.

4. Ci. ark, C. W.: Syphilis has not been conquered. Today’s

Health 35:41, 1957.

5. Venereal diseases, report of the Department of Health of
New York City 1955-56, p. 104.

6. Rosahn. P. D. : Screening for venereal disease. J. Chr. Dis.

7:140, 1958.

7. Beerman, H., Schamberg, I. L., Nicholas, L., and Green-
berg, M. S.: Syphilis, review of recent literature. Arch. Int.

Med. 99:791, 1957.

8. Editorial, Am. J. Pub. Health. May, 1958.

9. King, Ambrose: “These dying diseases” Venereology in de-

cline? Lancet 1:651, 1958.

10. Parran, Thomas: Syphilis control. Am. J. Pub. Health 22:
141, 1932.

11. Clark, E. Gurney, and Danbolt, N.: Oslo study of the

natural history of untreated syphilis. J. Chr. Dis. 2:311. 1955.

12. Gjf.sti-AXI), T.: The Oslo study of untreated syphilis; epi-

demiologic investigation of natural course of syphilitic infec-
tion based upon re-study of Boeck-Bruusgaard material. Acta
dermat.-venereol. (supp. 34) 35:1, 1955.

13. Today’s venereal disease control problem. Joint Statement,
Association of State and Territorial Health Officers, American
Venereal Disease Association, American Social Hygiene Asso-
ciation, February 1958.

530

THE JOURNAL-LANCET

Clinical Evaluation of Methocarbamol
(Robaxin) in an Industrial Facility

CARL S. PLUMB, M.D.

Pisgah Forest, North Carolina

Some of the complaints most frequently en-
countered in industrial medical practice in-
volve skeletal muscle spasm. In treating these
patients, the industrial physician is faced with a
dual challenge. First, he must attempt to pro-
vide sufficient relief so that the worker can re-
turn to his job in a full or limited capacity.
Second, he must be sure that the worker can per-
form his duties in a safe manner; for, surely, we
are not practicing good industrial medicine if we
relieve symptoms and, at the same time, induce
side effects that might render the worker vulner-
able to accident or injury.

Although this problem has long plagued in-
dustry, no regimen of therapy has been devised
to provide uniformly satisfactory results. Several
muscle relaxant agents have been employed with
varying degrees of success, both alone and in
combination with other drugs and physiother-
apy. For years mephenesin enjoyed popularity
as a drug of choice. It showed promise initially
and had many attributes recommending it as a
good skeletal muscle relaxant. It did, in many
cases, effectively diminish muscle spasm but with
one drawback— for maximal effect, the drug had
to be administered intravenously and, at most,
only a brief and transient remission of symptoms
was achieved. However, this was a successful
beginning and proved that the rationale was
sound. Then, in 1956, zoxazolamine, a compound
chemically unrelated to mephenesin, became
available. For a period, zoxazolamine enjoyed the
spotlight as a popular muscle relaxant.

In the fall of 1957, the latest entry into this
field, methocarbamol (Robaxin), was introduced.
Pharmacologic evidence reported by Morgan and
associates1 described the extended activity of this
new agent as compared to mephenesin.

Several recent clinical reports on the use of
Robaxin in a variety of skeletal muscle dis-
orders r> have described the efficacy, safety, and
therapeutic scope of this drug. This report pre-

carl s. plumb is assistant medical director of the
Olin Mathieson Chemical Corporation, Pisgah Forest,
North Carolina.

sents our observations on the results obtained
with this skeletal muscle relaxant in 60 industrial
workers.

PLAN OF STUDY

All patients were drawn from the 2,500 workers
of a chemical and paper manufacturing industry.
These individuals encompassed a good cross
section of the employee population, including
both sexes as well as all age groups. However,
care was taken to include in this study only
workers who, on their initial examination, were
considered to have uncomplicated skeletal mus-
cle spasm. Roentgenograms were taken in all
questionable cases to exclude bone or joint pa-
thology. All individuals with known chronic dis-
ease were easily eliminated, since the author was
familiar with each worker’s medical background.
According to their situation, different varieties of
acute skeletal muscle spasm are distinguished
and are represented in this report.

The minimal dose of Robaxin necessary for a
satisfactory response in this study was found to
be 1 gm. (2 tablets) everv four hours. Smaller
doses did not produce the desired results. Much
larger doses have been used by other investi-
gators3’4 with an enhanced therapeutic response
and a minimum incidence of side effects.

RATING OF RESPONSE TO THERAPY

The response to therapy was rated as follows:

Excellent— complete relief of symptoms within
one hour and the ability to return to full duty.

Good— moderate relief of symptoms with the
ability to return to work in a restricted capacity.

Fair— slight improvement of symptoms and the
ability to return to light duty at the beginning of
next shift without loss of time, thus preventing a
lost time type of injury.

None— no relief of symptoms and inability to
return to light duty after twenty-four hours.

RESULTS

The area of skeletal muscle involvement and the
response to Robaxin therapy is outlined in table
1. It should be emphasized that this response not

DECEMBER 1958

531

TABLE 1

RESPONSE TO METHOCARBAMOL THERAPY

Muscles Affected

Neck

Shoulder

Thorax

Lumbar region
Upper extremity
Lower extremity
Total

Excellent Good Fair None

0 110
0 7 11

0 3 0 0

0 21 2 3

0 5 1 0

16 0 1

7 43 5 5

(12*) (72%) (8%) (8%)

only includes relief of symptoms but also the
worker’s ability to return to his job. In these
terms of reference, 92 per cent of the group were
benefited by Robaxin. This included 7 patients,
or 12 per cent, who were completely relieved of
symptoms within one hour and were able to re-
turn to full duty. In addition, 43 individuals
had a good response. They derived moderate
relief of symptoms and could return to work in
a restricted capacity. Response was fair in 5
patients, or 8 per cent of the group. Their
symptoms slightly improved, and they were able
to return to light duty at the beginning of the
next shift without loss of time. Only 5 persons
out of 60, or 8 per cent, did not experience any
benefit from the medication.

Probably, in an industrial facility, the side
effects produced by a drug are as important as
the beneficial results obtained. This is a real
consideration when employees are active around
industrial equipment and injuries due to lack of
concentration or awareness can be frequent. It
was, therefore, interesting to note that no side
effects were observed in any of these patients.

DISCUSSION

The symptoms of muscle spasm may come on
suddenly or gradually, but thev usually consist
of pain on movement and tenderness on pres-
sure. Sometimes the spasm is the result of vol-
untary guarding processes brought into play as
a means of preventing any movement for fear of
producing pain. Usually, the symptoms are con-
fined to one muscle or a group of muscles.

The patient may have a spasm in the lumbar
region, which most frequently involves the apon-

euroses of the erector spinae and latissimus dorsi.
The pain is often intense and it may markedly
affect locomotion. In many instances, the onset
of pain can be traced to some physical exertion.
Another type involves the thorax in which the
sheaths of the pectoral muscles, intercostals, or
serratus magnus are more commonly affected. A
stiff neck involves the cervical muscles, especial-
ly the sternocleidomastoid. Again, the condition
may be the shoulder syndrome or the “charley-
liorse” of the lower extremities. Whatever the
cause or wherever the involvement, the patient
seems to think that there should be a simple
remedy for such a simple symptom complex.
Unfortunately, this is seldom the case. Those
overstretched and injured muscle fibers prove
extremely resistant to therapy.

Since the primary concern of the industrial
physician is the physical well-being of the worker
in relation to his duties, our results indicate that
Robaxin is indeed a worthwhile addition to the
therapeutic armamentarium.

SUMMARY

A group of 60 industrial workers, each with un-
complicated skeletal muscle spasm of sufficient
severity to affect their ability to perform their
duties, were treated with methocarbamol.

Results were gratifying in that 55 workers, or
92 per cent, could return to full or light duty.

No side effects were encountered.

CONCLUSION

In this study, methocarbamol (Robaxin) was
found effective in reducing skeletal muscle spasm
without side effects, and it is a safe drug, which
the industrial physician may use with confidence.

Methocarbamol (Robaxin) was supplied for this study
by A. H. Robins Co., Inc., Richmond, Virginia.

REFERENCES

1. Morgan, A. M., Truitt, E. B., Jr., and Little, J. M.:
Plasma lesels of mephenesin, mephenesin carbamate, guaiacol
glyceryl ether, and methocarbamol (AHR-85) after oral and
intravenous administration in dog. J. Am. Pharm. A. (Scient.
Ed.) 46:374, 1957.

2. Carpenter, E. B.: Methocarbamol as a muscle relaxant.

South. M. J. 51:627, 1958.

3. Park, H. W.: Clinical results with methocarbamol, a new

interneuronal blocking agent. J.A.M.A. 167:168. 1958.

4. Forsyth, H. F.: Methocarbamol (Robaxin) in orthopedic

conditions. J.A.M.A. 167:163, 1958.

5. O’Doherty, D. S., and Shields, C. D.: Methocarbamol — •

new agent in treatment of neurological and neuromuscular
diseases. J.A.M.A. 167:160. 1958.

oo2

THE JOURNAL-LANCET

Stricture of Esophagus
Due to Accidental
Ingestion of
Clinitest Tablet

ROBERT L. McFADDEN, M.D.
Jamestown, North Dakota

Cancel

CLINICAL

REVIEWS

Fig. 2. Bougie shown approaching stricture and passing
through it.

Review of medical literature reveals 4 cases
of esophageal stricture caused by ingestion
of Clinitest urine-testing tablets used by diabetic
patients.

The first case reported by Bloomer and Kirch-
ner1 involved a 14-year-old white diabetic girl
who was treated bv esophagoscopy and dilation.
This was followed by mediastinitis, after which
external operation was performed with segmental
resection of the stenosed portion of the esopha-
gus. Dilation was used following the surgery.

The next report- by Laskv is that of a 64-year-
old diabetic woman who was treated by esopha-
goscopy and repeated dilations over a swallowed
silk thread.

In 1957, Canbv’s report3 involved a 3-year-old
child and a 23-month-old child. The treatment
is not described.

CASE REPORT

Mrs. O. M. C., a doctor’s widow, aged 60, was seen on
March 8, 1955, complaining of inability to swallow even
liquids. History revealed that she had accidentally in-
gested a Clinitest tablet mistaking it for a Caroid tablet.
She immediately used the antidotes recommended — fruit

robert l. mc fadden, a specialist in ophthalmology
and otorhinolaryngology, is on the staff of the DePuy-
Sorkness Clinic, Jamestown.

DECK M BE H 1958

533

juice, Wesson oil, and olive oil — which induced vomit-
ing. Following this, a burning sensation was experienced
in the epigastrium, which was the first pain noted. Dys-
phagia and choking were experienced the next day but
no further burning or pain.

Increasing dysphagia was noted on the following nine
days, at which time the patient was seen at the clinic.
Barium swallow (figure 1) on March 8, 1955, showed a
markedly narrowed segment 4 to 5 cm. in length at the
junction of the upper and middle third of the esophagus.
Obstruction was not complete, and thin barium passed
readily. No other narrowed segments were demonstrated.
The stomach and duodenal cap were normal. Two days
later in the office, a 7 mm. Sippy dilating olive bougie
on flexible coiled wire pusher was passed under fluoros-
copy (figure 2) after Pontocaine anesthesia had been
administered by spray and gargle to the pharynx. Dila-
tion was carried out nine times during the next three
months, gradually increasing the size of the olive dilator
to 15 mm.

The patient has remained symptom-free since that
time, and, when last seen in December 1957, barium
swallow (figure 3) revealed a slight residual narrowing
which does not cause any difficulty.

COMMENT

Esophagoscopy or passing a bougie over a
thread, which are added safeguards in this type
of case, were not done because of the relative
ease with which the dilators passed under fluoro-
scopic view and also because of the patient’s fine
cooperation.

SUMMARY

The clinical course of a case of esophageal stric-
ture produced bv an innocent appearing caustic
tablet has been described. Although these bot-
tles are adequately labeled “poison, " it would
seem desirable to keep them away from any
other medication which is taken orally. Diabetic
patients should be warned of the danger in-
volved when these tablets are misused.

REFERENCES

1. Bloomer, W. E., and Kirchneh, J. A.: Esophageal stricture.
Connecticut M. J. 19:91, 1955.

2. Lasky, M. I.: Stricture of esophagus due to accidental in-

gestion of urine testing tablet (Clinitest). Illinois M. J. 109:
30, 1956.

3. Canhy, I. P.: Clinitest produces esophageal stricture, report
of 2 cases. J. Pediat. 50:68, 1957.

Fig. 3. Roentgenogram two years after ingestion of
Clinitest tablet. Residual narrowing at the site of the
former stricture is shown.

This department of The Journal-Lancet is devoted to reports on
cases in which all the appropriate diagnostic criteria have been
employed, the best known treatment administered and the results
recorded. It is desired that these case reports be so prepared that
they may be read with profit by physicians in general practice,
hospital residents and interns and may be of considerable value to
junior and senior students of medicine. This department welcomes
such reports from individuals or groups of physicians who have
suitable cases which they desire to present.

534

THE JOURNAL-LANCET

Leo G. Rigler, M.D.

H. MILTON BERG, M.D., and
HAROLD O. PETERSON, M.D.

DR. Leo G. Rigler, the new president of the Ra-
diological Society of North America, has long
been known internationally as a radiologist, teacher,
and clinician. Although his contributions to medi-
cine and radiology are legion, he will be best re-
membered by his students for his extraordinary abil-
ity and tireless enthusiasm as a teacher. Perhaps
because of his background in general practice and
early training in internal medicine and pathology,
but more likely because he is Leo Rigler, he pos-
sesses an unusual faculty for correlating the roent-
gen findings with the clinical signs and pathology.
Drawing from a vast storehouse of general medical
knowledge, he approaches diagnostic problems in
an analytical and logical manner and almost in-
variably arrives at the correct diagnosis. In addi-
tion, he has a remarkable facility for interpreting
radiology to medical students and to all other phy-
sicians, which has done much to give roentgen diag-
nosis its proper stature in medicine.

Dr. Leo G. Rigler was born in Minneapolis on
October 16, 1896. He obtained his early education
in the public schools in Minneapolis and entered
the University of Minnesota, where he obtained his
academic and medical training, receiving his M.D.
degree in 1920. While serving his internship in the
St. Louis City Hospital, he came in contact with
the stimulating work then being done by Dr. LeRov
Saute. This made a great impression on the young
intern and kindled his interest in radiology.

After completing his internship in 1921, Dr. Rigler
set up general practice in the small community of
New England, North Dakota. He bought an x-ray
machine and taught himself its use. He soon re-
alized that he would not be happy in general prac-
tice and returned to the University of Minnesota as

Reprinted with permission of authors and Radiology
(February 1958).

a resident in internal medicine and pathology in
1922. During his residency, it was noted that his
major interest was in radiology and, fortunately for
that specialty, he was soon given the opportunity to
concentrate his training in that department. He has
remained in radiology ever since. The latter part of
the year 1924 was spent with Dr. J. T. Case at the
Battle Greek Sanitarium and Dr. P. J. Hickey at the
University of Michigan.

Dr. Rigler went to Sweden in 1926 and spent the
greater part of the year with Dr. Giista Forssell at
the Caroline Institute in Stockholm. He became very
proficient in Swedish during that year. After com-
pletion of his work with Dr. Forssell, he spent some
months visiting other European clinics.

Upon his return from Europe in 1927, Dr. Rigler
was appointed associate professor of radiology at
the University of Minnesota and, in 1929, became
full professor. In 1935, he was made head of the
Department of Radiology, a position which he held
until his recent resignation in June 1957. He was
also chief of the Department of Radiology at the
Minneapolis General Hospital from 1927 to 1957.
During this same period, he was a radiological con-
sultant to several hospitals in Minneapolis. From
1925 to 1936, he maintained a private office in
downtown Minneapolis with Dr. Walter H. Ude.

The University of Minnesota erected a special and
unique building in 1936 known as “The Center for
Continuation Study” to be devoted to postgraduate
education. In 1937, Dr. Rigler established there an
annual one-week course in postgraduate radiology.
Many famous American and foreign radiologists have
participated in the presentation of these courses and
the attendance has risen steadily, being well over
300 in 1957.

Dr. Rigler served as senior consultant at the Vet-
erans Administration Hospital in Minneapolis and
is a consultant for the Tuberculosis Division of the

DECEMBER 1958

535

United States Public Healtli Service and the Armed
Forces Institute of Pathology. He is a member of
the National Advisory Cancer Council, the Com-
mittee on Radiology of the National Research Coun-
cil, the Lung Cancer Research Committee of the
American Cancer Society, and a trustee of the
American Board of Radiolog}’.

Dr. Rigler is a member or honorary member of
many American radiological and medical societies
and has held the following offices: first president of
the Minnesota Radiological Society; president oi the
Minnesota Pathological Society; chancellor of the
American College of Radiology; chairman of the
Section of Radiology of the American Medical Asso-
ciation; trustee of the American Registry of X-Ray
Technicians, representing the Radiological Society
of North America; and first vice-president of the
Radiological Society of North America. He is a fel-
low of the American College of Radiology and the
American College of Chest Physicians. He is an hon-
orary member of 9 foreign radiological and chest
societies. He is an associate editor of Radiology,
assistant editor of Diseases of the Chest, and on the
editorial board of Surgery and General Practice.

He was sent to Japan as a consultant with the
medical mission of the United States Army in 1950.
As a member of the visiting team of scientists of
the World Health Organization and Unitarian Serv-
ice Committee, he visited Israel and Iran in 1951
and India in 1953.

He has given the following honorary lectures:
Carman Lecture at the St. Louis County Medical
Society; Pancoast Lecture in Philadelphia; Hickey
Lecture in Detroit; Golden Lecture in New York;
Radiology Lecture of the Canadian Medical Associa-
tion; and the Crookshank Lecture in London. He
was the Caldwell Lecturer of the American Roent-
gen Ray Society in October 1958.

He has received the bronze medal of the American
Medical Association, the silver medal of the Southern
Minnesota Medical Association, the gold medal of
the Radiological Society of North America, and the
Crookshank palladium medal of the Faculty of Ra-
diologists of Great Britain.

Dr. Rigler has edited or written three books. He
has been the author or co-author of almost 200 pa-
pers. Some of the more important and original ar-
ticles have dealt with the following: the early diag-
nosis and movement of pleural effusions; use of the
visualized esophagus in the diagnosis of heart dis-
ease; roentgen visualization of the liver and spleen

with thorium dioxide sol.; the early diagnosis, the
duration, and evolution oi carcinoma oi the lung;
the latent period in the roentgen diagnosis of pul-
monary tuberculosis; the roentgenological manifesta-
tions of pulmonary edema; the early diagnosis of
carcinoma of the stomach; pernicious anemia and
tumors of the stomach; benign gastric tumors; and
acute abdominal conditions and intestinal obstruc-
tion.

In 1943, Dr. Walter H. Ude, with the assistance
of Dr. Rigler’s former students and his many friends,
established an annual Rigler lectureship at the Uni-
versity of Minnesota. The Rigler Lecture is usually
given at the time of the Continuation Course in Ra-
diology and has been presented by outstanding radi-
ologists in this country and abroad. This is one of
the few lectureships established in honor of someone
in his prime and indicates the high position Dr.
Rigler holds in the eyes of his colleagues. Dr. Fred
Jenner Hodges, professor of radiology at the Uni-
versity of Michigan and long time friend of Dr.
Rigler, presented the first Rigler Lecture. Dr. Rig-
ler was further honored in 1952, when his friends
and former students arranged to present him with
an oil painting of himself.

In 1920, Dr. Rigler was married to Matvl Sprung,
a college classmate. They have three children —
Ruth, Nancy, and Stanley or “Jack.” Ruth is a
writer and a story analyst. Nancy Rigler Saxon is
married to a resident in surgery at the University
of Minnesota, and they have three children. Dr.
“Jack” Rigler is a resident in surgery at the Univer-
sity of Chicago. Matvl Rigler has always held open
house whenever a visiting radiologist was in Minne-
apolis. She is a charming and gracious hostess, and
many radiologists from all parts of the world have
enjoyed the Rigler hospitality.

In 1957, Dr. Rigler resigned his professorship at
the University of Minnesota and moved to Los An-
geles. This was perhaps the most difficult decision
of his career. He continues to be more active than
most voung men in radiology in his capacity as con-
sultant and director of education in the Department
of Radiology at the Cedars of Lebanon Hospital.
Los Angeles, and visiting professor of radiology at
the University of California, Los Angeles, in ad-
dition to his many duties with national societies and
world-wide lecture commitments.

The Radiological Society of North America not
only honored Dr. Leo G. Rigler but honored itself
in electing him its president.

536

THE JOURNAL-LANCET

SERVING THE MEDICAL PROFESSION OF MINNESOTA,
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

INDEX TO VOLUME 78

January 1958 through December 1958

SUBJECT INDEX

AGED, outlook of vascular surgery upon, 329
Androgen-estrogen preparation, oral, suppression of lac-
tation with, 491

Anesthesiologist’s approach to prevention of operating
room deaths, 64

Angina pectoris treated by relaxation and automatic at-
tentive respiration, 7

Arthritides, drug synergism in the management of, 185
Asthma,

eczema, and allergic rhinitis in infancy and childhood,
373

medicinal treatment of, 105

BLEEDING, rectal, in infants and children, 86
Book Reviews,

Anatomies of Pain ( K. D. Keele), 33
Anatomist at Large (G. W. Corner), Dec. 26A
Ankylosing Spondylitis (j. Forestier, F. Jacqueline,
and Rotes-Querol ), 286

Atomic Age and Our Biological Future, The (II. V.
Bronsted), 368

Atomic Energy in Medicine ( K. E. Hainan), 112
Bedside Diagnosis (C. Seward), 112
Bone Tumors (D. C. Dahlin), Dec. 26A
Brain Mechanisms and Drug Action (W. S. Fields),
June 40 A

Chronically 111, The ( J. Fox), March 26A
Clinical Gastroenterology (E. D. Palmer), 149
Clinical Pathology Data ( C. J. Dickinson), 112
Conquest of Bovine Tuberculosis in United States
(H. R. Smith), 424

Dermatologic Formulary (F. Pascher), May 24A
Dermatologist’s Handbook, The (A. L. Welsh), 416
Diagnosis and Treatment of Endocrine Disorders in
Childhood and Adolescence ( L. Wilkins), Jan. 24A
Diagnosis and Treatment of Postural Defects, The
(W. M. Phelps, R. J. H. Kiphuth, and C. W. Goff),
454

Diseases of the External Ear ( B. II. Senturia), 286
Doctors and What They Do ( II. Coy), May 26A
Early Diagnosis and Treatment of Acoustic Nerve Tu-
mors, The ( J. L. Pool and A. A. Pava), 150
Etiologic Factors in Renal Lithiasis (A. J. Butt), 112
Fundamentals of Clinical Neurophysiology ( P. O.
Chatfield), 149

Gynecologic and Obstetric Pathology (Emil Novak
and Edmund Novak), 500
High Arterial Pressure ( F. H. Smirk), 368
History of Public Health, A (G. Rosen), 416
Human Blood Coagulation and Its Disorders (R. Biggs
and R. G. MacFarlane), July 22A
Human Ear Canal. The (E. T. Perry), Aug. 18A
Human Perspiration (Y. Knno), 368
Hypertension (I. H. Page), Feb. 24A
Hypnography: A Study in the Therapeutic Use of
Hypnotic Painting (A. Meares), 156
Hypophysectomy (O. H. Pearson), 368
Inhalation Analgesia in Childbirth (E. II. Seward and
R. Bryce-Smith), 156

International Nomenclature of Yaws Lesions, An (C.
J. Hackett), July 22A

Introduction to Anesthesia: The Principles of Safe

Practice (Robert D. Dripps), 33
It Pays to Be Healthy (R. C. Page), 150
Kaposi’s Sarcoma: Multiple Idiopathic Hemorrhagic

Sarcoma (S. M. Bluefarb), 454
Lens Materials in the Prevention of Eye Injuries (A.
H. Keeney), 500

Liver-Brain Relationships (I. A. Brown), Aug. 18A
Lupus Nephritis ( R. C. Muehrcke, R. M. Kark, C. L.

Pirani, and V. E. Pollack), Feb. 22A
Medical Interview, The (A. Meares), June 43A
Medical Radiation Biology ( F. Ellinger), May 24A
Merck Manual of Diagnosis and Therapy (Merck and
Co., Inc.), Feb. 22A

Methods in Surgical Pathology (IT. A. Teloh), May
26A

Multiple Neurofibromatosis ( F. W. Crowe, W. [.

Schull, and J. V. Neel), July 22A
Natural Childbirth (II. B. Atlee), Feb. 24A
Nerves Explained: A Straightforward Guide to Nerv-
ous Illnesses ( R. Asher), 327
Non-Venereal Syphilis: A Sociological and Medical

Study of Bejel (E. H. Hudson), 286
Pathology for the Physician (W. Boyd), Dec. 26A
Physics for the Anaesthetist Including a Section on
Explosions (R. Macintosh, W. M. Muslim, and II.
G. Epstein), 451

Physiopathology of the Reticulo-Endothelial System
(edited under direction of B. N. Halpern), Feb.
22A

DECEMBER 1958

537

Pica (M. Cooper), Nov. 32A

Postoperative Chest, The (H. T. Langston, A. M. Pan-
tone, and M. Melamed), 424
Progress in Radiobiology ( |. S. Mitchell, B. E. Holmes,
and C. L. Smith), Feb. 22A
Psychiatric Education and Progress ( |. C. Whitehorn)
March 26A

Psychobiology (A. Meyer), 416

Recurrent Laryngeal Nerves in Thyroid Surgery, The
(W. H. Rustad), Feb. 22A
Regulation and Mode of Action of Thyroid Hormones
( G. E. YV. Wolstenholme and E. C. P. Millar), Jan.
24A

Roentgenology ol the Chest ( C. B. Rabin), 500
Salient Points and the Value of Venous Angiocardiog-
raphy in the Diagnoses of the Cyanotic Types of
Congenital Malformations of the Heart, The ( B. M.
Casul, G. Hait, and. E. H. Fell, 112
Spinal Anesthesia (J. B. Dillon), 327
Spine: Anatomico-Radiographic Studies, Development
and the Cervical Region, The (L. A. Hadley), May
24A

Spontaneous and Habitual Abortion (C. T. |avert),
Dec. 26A

Stress and Strain in Bones ( F. G. Evans), |uly 22A
Surgical Management of Pulmonary Tuberculosis, The
(John D. Steele), Jan. 26A
Urine and the Urinary Sediment ( R. W. Lippman),
May 24A

Urology and Industry ( L. P. Wershub), Jan. 26A
CANCER,

endometrial, apparent relationship between Stein-
Leventhal syndrome and, 417
of thyroid gland, premature resort to x-ray therapy a
common error in treatment of, 478
progress in control of, 270
viruses and their relationship to, 174
Chest, injury from blunt trauma to the: its manage-

ment in the community hospital, 124
Children of America need our help, 167
Clinical manifestations of the autonomic nervous system
sequential to osteoarthritis of the cervical spine, 197
Colfax tornado disaster, 361
Colic in infancy, 60
Colostomy, care of patient with a, 16
Convulsions, recurrent, treatment of, in children, 461

DEAFNESS, toxic drugs and, 505
Diabetic,

acidosis, treatment of, 37

children’s camp, use of multi-interval blood glucose
method in, 378

Diehl, Harold Sheely, M.D., 311
Digests of Current Literature on Pain:

Analgesics and Their Antagonists: Some Steric and
Chemical Considerations. Part 111. The Influence
of the Basic Croup on the Biological Response (A.
lb Beckett, A. F. Casy, and N. J. Harper), 35
Assessment of the Cardiac Patient for Anaesthesia, The
(A. J. W. Beard and J. F. Goodwin), 35
Basal Hypnosis by the Rectal Administration of a
Multidose Thiobarbiturate Suppository ( S. N. Al-
bert, H. N. Eccleston, Jr., J. S. Boling, and C. A.
Albert), 158

Circulatory Responses During Anesthesia of Patients
on Rauwolfia Therapy ( C. S. Coakley, S. Alpert,
and J. S. Boling), 452

Contribution to the Therapy of Myocardial Depression
Caused by Thiopentone Sodium (Studied by High

Frequency Cardiomyography ) (A. Fronek and Z.
Pisa), 36

Cortisone and Anesthesia (S. W. Gorens), 35
Effect of Nisentil ( Alphaprodine) Hydrochloride and
Lorfan T. M. ( Levallorphan ) Tartrate on Respira-
tion ( |. Auerbach and C. S. Coakley), 328
Facial Nerve Paralysis after General Anesthesia ( j. E.

Fuller and D. V.’ Thomas), 156
Fatalities Following Topical Application of Local Anes-
thetics to Mucous Membranes ( |. Adriani and D.
Campbell ) , 35

Geriatric Patient and Anesthesia, The (R. H. Barrett),

157

Herniorraphy in the Poor-Risk Patient (P. H. Bcves
and C. II. J. Rey), 328

Nitrous Oxide, Trichlorethylene, and Ether: A Bal-

anced Anesthesia in Obstetrics ( L. N. Cheeley), 452
Pediatric Anesthesia ( L. D. Bridenbaugh, |r. ), 36
Physiology of the Adrenal Gland (J. H. Burn), 452
Prevention, Recognition and Treatment of Postopera-
tive Atelectasis (P. A. Clayton), 452
Pudendal Block: Two New Techniques (V. Apgar),

158

Respiratory Adjustments to Increases in External Dead
Space (G. B. Clappison and W. K. Hamilton), 453
Studv of Hypodermic Needle Points ( F. Franz and
R. M. Tovell), 156

Vomiting and Regurgitation During and After Anes-
thesia; Some Causes, Effects, Prevention and Man-
agement (j. Adriani), 157
Diseases, systemic, lesions of the oral mucosa in, 336
Donahoe, Will E., M.D., physician, educator, and hu-
manitarian, 71

Drug synergism in the management of arthritides, 185
Drugs, newer hypotensive, comparative clinical pharma-
codynamic evaluation of, 19

Duodenum, congenital atresia of, twenty-one-year inter-
val report, 465

Dysmenorrhea, primary, current concepts and treatment,
'322

ECZEMA, allergic rhinitis, and asthma in infancy and
childhood, 373
Editorials:

Common Pain and an Uncommon Problem, A, 34
Health Supervision of Children, 1 1 1
Last Tubercle Bacillus, 148
“Lest We Forget,” 205
Nursing Home Care, 499
Radiation Hazards, 147
Education,

professional, for better health, Minnesota shares in, 284
professional, in WHO programs, 237
Emergency room patient, some responsibilities of the
physician in care of, 508

Epilepsy, childhood, general principles for drug therapy
in, 182

Erythema nodosum, 303

Esophagus, stricture of, due to ingestion ol
Clinitest tablet, 533

FARGO tornado — medical aspects, 307
Femoral,

head replacement prostheses, study of, 369
shortening for equalization of leg length, 1
Food and health, 254
Fractures,

compound, modern treatment of, 290
multiple, immediate planning for definitive treatment
of severely injured individuals with, 103

538

THE JOURNAL-LANCET

gynecology,

office, 91

Pelvic pain in women — a universal problem, 151
HEALTH,

better, Minnesota shares in professional education for,
284

contribution of the hospital to improvement of, 264
education, role of, in raising standards of world
health, 243
food and, 254

international, in the Americas, 223
international, voluntary agencies in, 261
occupational, international aspects of, 251
of the American Indians, 108
programs, world, nursing in, 245

world, role of health education in raising standards
of, 243
I Ieart,

disease — a world health problem, 266
disease, surgery in, 73
Hemorrhage, spontaneous subarachnoid, 82
Herpes simplex virus infections, recurrent, vaccinia virus
immunization of patients with, 501
Hoarseness and related voice disorders, clinical signifi-
cance of, 50

Hodgkin’s disease, intermittent obstructive jaundice in:
report of a case, 99

Hormone support, sex, for castrate or senescent woman —
TACE with Androgen: review of, experience, 343
Hypertension, curable, 472

INFANTS, colic in, 60

Injury from blunt trauma to the chest: its management
in the community hospital, 124

|AUNDICE, intermittent obstructive, in Hodgkin’s dis-
ease: report of a case, 99

LACTATION, suppression of with an oral androgen-
estrogen preparation, 491
Lancet Clinical Reviews: 69, 320, 366, 533
Laryngology,

clinical significance of hoarseness and related voice
disorders, 50

Lips, incomplete cleft, surgical repair of, 366

MALARIA incidence in the world today, 248
Maternal mortality in North Dakota, 421
Mayer, Roland G„ 1891-1958, 199
Mechanism of parathyroid function, 190
Meningitis, meningococcic, and meningococcemia with
probable Waterhouse-Friderichsen syndrome, 69
Meningococcemia, meningococcic meningitis and, with
probable Waterhouse-Friderichsen syndrome, 69
Methocarbamol (Robaxin) in an industrial facility, clin-
ical evaluation of, 531

Meyerding, Edward A., M.D., physician, educator and
friend, 142

Migraine, unusual manifestations of, 449
Mucosa, oral, lesions of in some systemic diseases, 336
Multiple sclerosis, prevalence and incidence of in Mis-
soula County, Montana, 358

NEONATAL period, observations on prevention of death
in, 484
Neuralgia,

tic douloureux, management of, 29
Nine years in the regional office in Southeast Asia, 216
North Dakota State Medical Association, transactions of,
381, 424

Not by bread alone, 160

Novak, Edward E., M.D. — pioneer doctor, educator, fi-
nancier, and animal husbandry expert, 363
Nursing in world health programs, 245

OBSTETRICS,

maternal mortality in North Dakota, 421
Obstetric emergencies in general practice, 294
Ocular symptoms, diagnostic value of, 1 1
Oral mucosa, lesions of in some systemic diseases, 336
Orthopedics,

femoral shortening for equalization of leg length, 1
Osteoarthritis of the cervical spine, clinical manifesta-
tions of the autonomic nervous system sequential to,
197

Ovarian tumors, 54
PAIN,

Dysmenorrhea, primary, current concepts and treat-
ment, 322

pelvic, in women — a universal problem, 151
tic douloureux, management of, 29
unusual manifestations of migraine, 449
Palmer, Carroll E., merits world-wide recognition, 319
Parathyroid function, mechanism of, 190
Pediatrics,

eczema, allergic rhinitis, and asthma in infancy and
childhood, 373

observations on prevention of death in the neonatal
period, 484

rectal bleeding in infants and children, 86
treatment of recurrent convulsions in children, 461
use of multi-interval blood glucose method in a dia-
betic children’s camp, 378
Pelvic pain in women — a universal problem, 151
Pericarditis, acute nonspecific, 77
Pilonidal disease, 46
Postoperative medical emergencies, 347
Power lawn mowers — a new hazard, 356
Prefatory note from the director-general of the World
Health Organization, 201
Prostheses, femoral head, study of, 369
Pseudohermaphrodism, female, case report, 320
Puberty, dysfunctional uterine bleeding during, 521
Public health,

animal health problems a challenge to, 274
in Africa, 207

in Eastern Mediterranean, 219
in Europe, 221
in Western Pacific, 214

international cooperation in, prior to establishment of
the World Health Organization, 233

RADIATION, ionizing, in medicine — a useful tool and
a hazard, 114

Rehabilitation of the disabled, 282
Rheumatic fever: a review, 510

Rhinitis, allergic; eczema, and asthma in infancy and
childhood, 373
Rigler, Leo G., M.D., 535

SANITATION, environmental, in a global setting, 240
Scarlet fever, 456

Stein-Leventhal syndrome and endometrial carcinoma,
apparent relationship between, 417
Stress in the world, the individual and the doctor, 280
Surgery,

in heart disease, 73

vascular, outlook of upon the aged, 329

DECEMBER 1958

539

TACE with Androgen for castrate or senescent woman;

review of experience, 343
Thrombophlebitis, trauma and, 43
Tic douloureux, management of, 29
Tolbutamide dilemma, 287
Tornado

disaster, Colfax, 361
Fargo — medical aspects, 307
Trauma and thrombophlebitis, 43
Tuberculin test, the, 132
Tuberculosis,

decade in retrospect and in prospect, 257
from man to animals, 138

in a controlled institutional environment, development
of, 162

spinal, and simulative disease, debridement and pan-
arthrodesis for, 351

Tumors, ovarian, 54
Tuohy, Edward L., M.D., 494

URINARY tract, injuries of, 467

Uterine bleeding, dysfunctional, during puberty, 521

Uterus didelphys — case report, 489

VACCINIA virus immunization of patients with recur-
rent herpes simplex virus infections, 501
Venereal disease control, years of progress in, 528
Viruses and their relationship to cancer, 174

WATERI lOUSE-Friderichsen syndrome, meningococcic
meningitis and meningococcemia with probable, 69
World Health Organization,
in an era of chemotherapy, 525
programs, professional education in, 237
ten years of progress, 226

AUTHORS INDEX

Adamson, B. C. (co-author). Debridement and panar-
throdesis for spinal tuberculosis and simulative dis-
ease: preliminary report, 351
Anderson, Gaylord W., “Lest we forget” (editorial),
205; Minnesota shares in professional education for
better health, 284

Arneson, W. A. (co-author), Congenital atresia of the
duodenum: twenty-one year interval report, 465

Banner, Edward A., Office gynecology, 91
Beierwaltes, W. H. (co-author), Premature resort to x-
ray therapy: a common error in treatment of car-

cinoma of thyroid gland, 478
Bellomo, James (co-author), Female pseudohermaphro-
dism, a case report, 320; (co-author), Unusual mani-
festations of migraine, 449

Berg, H. Milton (co-author), Leo G. Rigler, M.D., 535;

Radiation hazards (editorial), 147
Bernstein, William C., Care of the patient with a colos-
tomy, 16

Black, |. Harvey, The medicinal treatment of asthma,
105

Blanchard, Kenneth (co-author), Drug synergism in the
management of arthritides, 185
Bosch, Herbert, Environmental sanitation in a global
setting, 240

Boudreau, Frank G., International cooperation in public-
health prior to establishment of the World Health
Organization, 233

Briggs, John F. (co-author), Female pseudohermaphro-
dism, a case report, 320; Surgery in heart disease, 73;
(co-author), Unusual manifestations of migraine, 449
Burgess, R. C., Food and health, 254

Burton, John, Role of health education in raising stand-
ards of world health, 243

Cambournac, F. [. C., Public health in Africa, 207
Candau, M. G., Prefatory note, 201

Carr, E. A., Jr. (co-anthor), Premature resort to x-ray
therapy: a common error in treatment of carcinoma
of thyroid gland, 478

Cavanagh, Denis, Obstetric emergencies in general prac-
tice, 294

Clark, E. Gurney, Years of progress in venereal disease
control, 528

Cottam, G. I. W. (co-author), Congenital atresia of the
duodenum: twenty-one-year interval report, 465
Crosby, Edwin L., Contribution of the hospital to the
improvement of health, 264

Darner, C. B. (co-author), Sex hormone support for
castrate or senescent woman — TACE with Androgen:
review of experience, 343
Diehl, Harold S., Progress in control of cancer, 270
Diessner, Grant R. (co-author), Intermittent obstructive
jaundice in Hodgkin’s disease: report of a case, 99
Dingledine, W. S. (co-author), Premature resort to x-rav
therapy: a common error in treatment of carcinoma
of thyroid gland, 478

Dixon, George L., Immediate planning for definitive
treatment of severely injured individuals with multiple
fractures, 103

Dodd, Paul S., The tuberculin test, 132
Dodds, G. A. (co-author), Fargo tornado — medical as-
pects, 307

Douglas, G. C. (co-author), Pelvic pain in women — a
universal problem, 151

Douglas, G. F. (co-author), Pelvic pain in women — a
universal problem, 151

Douglas, G. F., Jr. (co-author), Pelvic pain in women —
a universal problem, 151

Douglas, Sarah F. (co-author), Pelvic pain in women —
a universal problem, 151

Douglas, W. W. (co-author), Pelvic pain in women — a
universal problem, 151

Evres, T. E. (co-author), Vaccinia virus immunization
of patients with recurrent herpes simplex virus infec-
tions, 501

Fang, I. C., Public health in the Western Pacific, 214
Farr, John, Trauma and thrombophlebitis, 43
Felland, O. M., Colfax tornado disaster, 361

540

THE JOURNAL-LANCET

Klink, Edmund B. (co-autlior), Treatment of diabetic
acidosis, 37

Ford, Ralph A. (co-author), Drug synergism in the man-
agement of arthritides, 185

Fremont, Rudolph E., Comparative clinical pharmaco-
dynamic' evaluation of newer hypotensive drugs, 19
Friedell, Aaron, Angina pectoris treated by relaxation
and automatic attentive respiration, 7

Gayral, Louis (co-author), Clinical manifestations of the
autonomic nervous system sequential to osteoarthritis
of the cervical spine, 197

Gelperin, Abraham, The development of tuberculosis in
a controlled institutional environment, 162
Gifford, Ray W., Curable hypertension, 472
Gillam, John S. (co-author), Sex hormone support for
castrate or senescent woman — TACE with Androgen:
review of experience, 343

Goldfarb, Alvin F. (co-author). Dysfunctional uterine
bleeding during puberty, 521; (co-author), Primary
dysmenorrhea: current concepts and treatment, 322
Goldwater, Leonard J., International aspects of occupa-
tional health, 251

Grzegorzewski, Edward, Professional education in WHO
programs, 237

Hall, R. R. (co-author), Debridement and panarthro-
desis for spinal tuberculosis and simulative disease:
preliminary report. 351

Hart, George M., Femoral shortening for equalization of
leg length, 1; Study of femoral head replacement pros-
theses, 369

Haunz, E. A., The tolbutamide dilemma, 287; Use of
the multi-interval blood glucose method in a diabetic
children’s camp, 378

Heck, Frank |. (co-author), Intermittent obstructive
jaundice in Hodgkin’s disease: report of a case, 99
Hirschboeck, Frank (., Edward L. Tuohy, M.D., 494
Hitchcock, Claude R. (co-author), Outlook of vascular
surgery upon the aged, 329

Hollenhorst, Robert W., The diagnostic value of various
ocular symptoms, 1 1

Horton, George W., The modern treatment of compound
fractures, 290

Hudgins, Herbert A., Health of the American Indians,
108

Hunter, G. Wilson (co-author), Sex hormone support
for castrate or senescent woman — TACE with Andro-
gen: review of experience, 343
Hyde, H. van Zile, The World Health Organization — -
ten years of progress, 226

Jackson, Byron (co-author), Fargo tornado- — medical as-
pects, 307

Johnson, Frank E., Injury from blunt trauma to the
chest: its management in the community hospital, 124

Keith, Haddow M., Treatment of recurrent convulsions
in children, 461

Keller, John M., Uterus didelphys — case report, 489
Kelly, James H., Acute nonspecific pericarditis, 77
Krusen, Frank II., Rehabilitation of the disabled, 282
Kurland, Leonard T. (co-author), Prevalence and inci-
dence of multiple sclerosis in Missoula County, Mon-
tana, 358

Lamb, Donald, Postoperative medical emergencies, 347
Landes, Herbert E. (co-author), Injuries ol the urinarv
tract, 467

Lindsay, D. i. (co-author), Fargo tornado — medical as-
pects, 307

Litzow, Thaddeus J., Surgical repair of incomplete cleft
lips, 366

Livingston, Samuel, General principles for drug therapy
in childhood epilepsy, 182

Loken, Merle K. (co-author), Ionizing radiation in
medicine — a useful tool and a hazard, 114
Lucy, Robert E. (co-author), Apparent relationship be-
tween the Stein-Leventhal syndrome and endometrial
carcinoma, 417

Lundy, John S., A common pain and an uncommon prob-
lem (editorial), 34

Maui, Chandra, Nine years in the regional office of
Southeast Asia, 216

Marvin, James F. (co-author), Ionizing radiation in
medicine — a useful tool and a hazard, 114
Mazzia, Valentino D., An anesthesiologist’s approach to
prevention of operating room deaths, 64
McClure, John N., Jr., Power lawn mowers- — a new haz-
ard, 356

McFadden, Robert L., Stricture of esophagus due to acci-
dental ingestion of Clinitest tablets, 533
McTver, Pearl, Nursing in world health programs, 245
Medovy, Harry, Observations on prevention of death in
the neonatal period, 484

Middleton, William S., Not by bread alone, 160
Moore, John 11., Maternal mortality in North Dakota,
421

Morse, George D., Tuberculosis from man to animals,
138

Mosser, Donn G. (co-author), Ionizing radiation in medi-
cine— a useful tool and a hazard, 114
Murphy, Thomas O. (co-author). Outlook of vascular
surgery upon the aged, 329
Myers, |. Arthur, Carroll E. Palmer merits world-wide
recognition, 319; Children of America need our help,
167; Edward A. Meyerding, M.D. — physician, edu-
cator, and friend, 142; Edward E. Novak, M.D. — pio-
neer doctor, educator, financier, and animal husbandry
expert, 363; Harold Sheelv Diehl, M.D. — physician,
investigator, educator, administrator, and benefactor
of mankind, 311; Last tubercle bacillus (editorial),
148; Roland G. Mayer, 1891-1958, 199; Will E. Dona-
hoe, M.D., physician, educator, and humanitarian, 71

Neuman, W. F., The mechanism of parathyroid func-
tion, 190

Neuwirth, Eugene (co-author). Clinical manifestations
of the autonomic nervous system sequential to osteo-
arthritis of the cervical spine, 197
Nicholl, Willard (co-author), Prevalence and incidence
of multiple sclerosis in Missoula Countv, Montana,
358

Norum, H. A. (co-author), Fargo tornado — medical as-
pects, 307

Olwin, Thomas K. (co-author), Treatment of diabetic
acidosis, 37

DECEMBER 1958

541

Palmer, Carroll E., Tuberculosis: a decade in retrospect
and in prospect, 257

Perkins, James E., Voluntary agencies in international
health, 261

Perry, Harold O., Lesions of the oral mucosa in some
systemic diseases, 336

Peterson, Harold O. (co-author), Leo G. Rigler, M.D.,
535

Petzing, Harry E. (co-author), Suppression of lactation
with an oral androgen-estrogen preparation, 491
Phelan, John T., Some responsibilities of the physician
in the care of the emergency room patient, 508
Pirtle, E. C. (co-author), Vaccinia virus immunization of
patients with recurrent herpes simplex virus infections,
501

Plumb, Carl S., Clinical evaluation of methocarbamol
(Robaxin) in an industrial facility, 531
Poser, Charles M., Management of tic douloureux, 29
Pray, Laurence G., Health supervision of children (edi-
torial), 111; Scarlet fever, 456

Raile, Richard B. (co-author), Erythema nodosum, 303;
(co-author), MeningOcoecic meningitis and meningo-
coccemia with probable Waterhouse-Friderichsen syn-
drome, 69

Randall, Clyde E., Ovarian tumors, 54
Rathbun, |. C., Rectal bleeding in infants and children,
86

Ripple, Rudolph )., ]r., Spontaneous subarachnoid hem-
orrhage, 82

Rusk, Howard A., Stress in the world, the individual and
the doctor, 280

Russell, Paul F., Malaria incidence in the world today,
248

Siedler, Howard 1). (co-author), Prevalence and inci-
dence of multiple sclerosis in Missoula County, Mon-
tana, 358

Snelling, Charles E., Colic in infancy, 60
Soper, Fred L., International health in the Americas, 223
Sorkness, [oseph (co-author), Apparent relationship be-
tween the Stein-Leventhal syndrome and endometrial
carcinoma, 417

Southam, Chester M., Viruses and their relationship to
cancer, 174

Spink, Wesley W., WHO in era of chemotherapy, 525

Steele, [ames H., Animal health problems: a challenge
to public health, 274

Stone, Martin L. (co-author), Dysfunctional uterine
bleeding during puberty, 521; (co-author), Primary
dysmenorrhea: current concepts and treatment, 322

Swaiman, Kenneth F. (co-author), Erythema nodosum,
303; (co-author), Meningococcic meningitis and me-
ningococcemia with probable Waterhouse-Friderich-
sen syndrome, 69

Swenson, John A. (co-author), Apparent relationship
between the Stein-Leventhal syndrome and endo-
metrial carcinoma, 417

Taba, A. H„ Public health in the Eastern Mediterranean,
219

Thompson, George (co-author). Sex hormone support
for castrate or senescent woman — TACE with Andro-
gen: review of experience, 343

Triggs, P. O. (co-author), Fargo tornado — medical as-
pects, 307

Tudor, Robert B., Eczema, allergic rhinitis, and asthma
in infancy and childhood, 373; Rheumatic fever, 510

Unher, Morris (co-author), Suppression of lactation with
an oral androgen-estrogen preparation, 491

van de Calseyde, Paul |. J., Public health in Europe, 221

Van Slvke, C. J., Heart disease — a world health prob-
lem, 266

Von Leden, Hans, Clinical significance of hoarseness
and related voice disorders, 50

Wehrs, Roger E., Toxic drugs and deafness, 505

Weisberg, |errv (co-author), Use of the multi-interval
blood glucose method in a diabetic children’s camp,
378

Wilson, Edward T. (co-author), Injuries of the urinary
tract, 467

Wright, Willard A., Nursing home care (editorial), 499

Zimmerman, Karl, Pilonidal disease, 46

542

THE JOURNAL-LANCET

needs support, too

• a •

during pregnancy
throughout lactation

Help protect her now, and you help insure bet-
ter future health for her and her baby. A single
NATABEC Kapseal each day provides all the
Vitamins and minerals the gravida or nursing
mother needs to supplement a well-rounded diet.

each NATABEC Kapseal contains:

Calcium carbonate 600 mg.

Ferrous sulfate 150 mg.

Vitamin I) (10 meg.) 400 units

Vitamin Bi (thiamine) mononitrate..., 3 mg.

Vitamin B2 (riboflavin) 2 mg.

Vitamin Bi* (crystalline) 2 meg.

Folic acid 1 mg.

Synkamin® (vitamin K) (as the hydrochloride) 0.5 mg.

Rutin 10 mg.

Nicotinamide (niacinamide) 10 mg.

Vitamin Be (pyridoxine hydrochloride) 3 mg.

Vitamin C (ascorbic acid) 50 mg.

Vitamin A (1.2 mg.) 4,000 units

Intrinsic factor concentrate 5 mg.

dosage As a supplement during pregnancy and throughout
lactation, one or more Kapseals daily. Available in bottles of
100 and 1,000.

Pathology for the Physician, by
William Boyd, M.D., 1958.
Philadelphia: Lea & Febiger, 900
pages. $17.50.

This is the sixth edition of Dr.
Boyd’s well-known text of general
pathology formerly entitled Pathol-
ogy of Internal Diseases. All sub-
jects have been brought up-to-date,
and much new material has been
introduced in old chapters, such as
a detailed discussion ol the carcinoid
syndrome and serotonin in the chap-
ter on intestinal diseases, plus the
addition of 3 new chapters covering
diseases of the joints, diseases of
muscles, and the physiology and
pathology of the internal environ-
ment. As previously, Dr. Boyd de-
votes much space to disturbed func-
tion as well as anatomic changes
and introduces into both phases of
his discussion the latest materials
available. There is an account of
the electron microscopic structure
of the glomerulus, needle biopsy of
the kidney, and other morphologic
advances together with the recent
work on enzyme activity in renal
tubular function, aldosteronism, and
so forth.

Dr. Bovd’s presentation is always
lucid and understandable. More im-
portant, the writing is extremely in-
teresting with occasional humorous
asides. Although somewhat short in
the fine details required of the
morphologic pathologist, it is of
value to the pathologist in under-
standing the disease from a physio-
logic point of view and is an ex-
cellent book for the internist in
correlating all phases of any parti-
cular disease process.

John Coe, M.D.

e

Bone Tumors, by David C. Dahlin,
M.D., 1957. Springfield, Illinois:
Charles C Thomas. $11.50.

This excellent treatise on bone tu-
mors has been needed for many
years. Dr. Dahlin’s well-known acu-
men and knowledge of bone tumors
has been applied to a review of
2,276 bone tumors which have been
carefully and personally studied by
the author at the Mayo Clinic. The
scope of this study is enormous, and
the volume is probably the most
concise and informative of its size.
Much of this work has been pre-
viously presented in separate papers
by Dr. Dahlin and his colleagues.
The format is particularly pleasing.
It is exceptionally readable and is
presented as briefly as possible. The
illustrations are of the finest quality.

This volume contains little that is
controversial. It is a book that every
pathologist and orthopedic surgeon
should have in his library.

John H. Moe, M.D.
e

Spontaneous and Habitual Abortion,

by Cahl T. J avert, M.D., 1957.

New York: McGraw-Hill Book

Co., Inc., 450 pages. $11.00.

In this volume, the author presents
his numerous contributions to the
literature of spontaneous abortion.
Foremost is a thoughtful and com-
prehensive review of 2,000 consecu-
tive abortuses, with discussion of the
pertinent physiology and pathology
well supplemented by numerous ill-
ustrations, case reports, and a num-
ber of entertaining cartoons. The
author has taken particular care to
examine decidual tissue and has ob-
tained curettage material in nearly
90 per cent of cases. He stresses
the value of labor records kept dur-
ing the course of expulsion of the
abortus and of examination of the
ovofetus and placenta in undis-
turbed condition. Thirty-five per
cent of these unselected specimens
showed abnormality of the ovofetus,
and significant abnormality of the
decidua was found in 93 per cent
of cases. The low incidence of
decidual abnormality in the control
series of unintentional and thera-
peutic abortions is used as evidence
that decidual pathology is primary
to abortion, not secondary to expul-
sion. The incidence of reported cord
abnormalities is exceptionally high,
but it represents observations of less
than one-third of all specimens. The
author reports no cases of incompe-
tent internal cervical os, but the
cases of premature dilatation of the
cervix that he reports could be
separated from the phenomena re-
ported by Lash and Lash only with
difficulty.

Dr. Javert’s views relative to the
etiology and prevention of habitual
abortion are well known and some-
what controversial. Many will dis-
agree with his observation of clinical

evidence of scurvy in one-third of all
women who abort. Many will ques-
tion the value of administration of
vitamins C, P, and K to habitual
aborters and the need for interdic-
tion of smoking in this group. The
evidence for the abortion-producing
effect of orgasm in contrast to the
purported safety of coitus without
orgasm must only be interpreted as
inconclusive. The author’s propo-
sition that the low reported abortion
rate in unwed mothers is due to their
lack of postconceptual coitus to or-
gasm is subject to some question.

Throughout the author’s discussion
of the management of the habitual
abortion patient, his deep concern
for the problem is obvious, as is the
enormous reassurance, encourage-
ment, and emotional support which
he gives his patients. One would
wonder whether this was not the
cornerstone of his therapeutic regime
and of signal import in effecting the
81 per cent cure rate which he
cites. Certainly, any regime yield-
ing this degree of success in these
vexing patients merits consideration.
It is interesting that no endocrine
therapy was employed.

The importance which Dr. [avert
attaches to emotional factors in the
production of abortion is manifest
by the size of the chapter on “Psy-
chosomatology.”

This volume will be of value to
many practitioners of obstetrics and
gynecology, and, to those trained in
psychiatric discipline, the exposition
of organic effects of emotion will be
of interest.

Thomas Kirschbaum, M.D.

•

Anatomist at Large, bv George \Y.

Corner. M.D., 1958. New York:

Basic Books, Inc., 215 pages.

$4.00.

This is a charming book by one of
the great leaders in embryologic
research. As physicians know, Dr.
Corner has made many studies on
the mammalian ovum and the way
in which it travels from the ovum
to the uterus where it develops to
maturity. He is a delightful per-
son who writes in a very interesting
manner. He has known many of the
great men in American medicine,
and he writes well about his con-
tacts with them. Every physician
who wishes to add to his education
will do well to read this book. It
is a wonderful volume to put in the
hands of a medical student, espe-
cially one who is thinking of going
into research.

Walter C. Alvarez, M.D.

'